CHAPTER 22: Pulmonic Valve

PULMONIC VALVE REGURGITATION

• Mild degrees of pulmonic valve regurgitation are common in normal individuals. This should be considered a normal variant.

• The regurgitant color flow jets may be eccentric.

• Scanning tip: Timing the jet with pulsed-wave Doppler, or with color M-mode Doppler, will help distinguish it from coronary artery flow and from a continuous communication between the aorta and the pulmonary artery.

• Note: Severe pulmonic valve regurgitation with normal pulmonary pressures may be of short duration and may have a low velocity.

• The guidelines integrate magnetic resonance imaging with echocardiography for quantitation of PR. This is particularly important in patients with congenital heart disease.

• Significant pulmonic valve regurgitation may be:

  • - An indicator of pulmonary diastolic hypertension.

  • - A consequence of pulmonary valve endocarditis.

  • - A sign of a bicuspid, quadricuspid, absent, or dysplastic pulmonic valve.

  • - Associated with a dilated pulmonary artery.

  • - Important in prior tetralogy repair.

  • - An indicator of a failing pulmonic homograft in a Ross procedure.

  • - Present in carcinoid pulmonic valve disease.

• Findings in severe pulmonary valve regurgitation:

  • - Jet width to RVOT ratio ≥70%.

  • - Pressure half time <100 ms.

  • - Early jet termination.

  • - Premature pulmonic valve opening.

  • - Pulmonary artery diastolic flow reversal.

Sources

• Dellas C, Kammerer L, Gravenhorst V, et al. Quantification of pulmonary regurgitation and prediction of pulmonary valve replacement by echocardiography in patients with congenital heart defects in comparison to cardiac magnetic resonance imaging. Int J Cardiovasc Imaging. 2018;34:607–613.

• Fathallah M, Krasuski RA. Pulmonic valve disease: review of pathology and current treatment options. Curr Cardiol Rep. 2017;19:108.

• Fernández-Armenta J, Villagómez D, Fernández-Vivancos C, et al. Quadricuspid pulmonary valve identified by transthoracic echocardiography. Echocardiography. 2009;26:288–290.

• Renella P, Aboulhosn J, Lohan DG, et al. Two-dimensional and Doppler echocardiography reliably predict severe pulmonary regurgitation as quantified by cardiac magnetic resonance. J Am Soc Echocardiogr. 2010;23:880–886.

• Takao S, Miyatake K, Izumi S, et al. Clinical implications of pulmonary regurgitation in healthy individuals: detection by cross sectional pulsed Doppler echocardiography. Br Heart J. 1988;59:542–550.

• Waller BF, Howard J, Fess S. Pathology of pulmonic valve stenosis and pure regurgitation. Clin Cardiol. 1995;18:45–50.

PULMONIC VALVE STENOSIS

• Valve opening:

  • - In pulmonic valve stenosis, the atrial contraction will open the stenotic valve a crack in late diastole, and it will then remain open until the end of systole, closing at the beginning of next diastole.

  • - The reason is that in isolated valvular pulmonic stenosis, the right ventricle becomes muscular and stiff but does not dilate.

  • - Atrial contraction elevates the pressure in this noncompliant right ventricle above the relatively low pulmonary artery diastolic pressure, and the valve opens and stays ajar.

  • - The appearance of partly open stenotic pulmonic leaflets is fused leaflets that dome with a circular orifice—like a short windsock, or the mouth of a volcano.

• Auscultation:

  • - The ejection click of valvular ...