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Pulmonic Stenosis

By

Guy P. Armstrong

, MD, North Shore Hospital, Auckland

Last full review/revision Aug 2021| Content last modified Aug 2021
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Pulmonic stenosis (PS) is narrowing of the pulmonary outflow tract causing obstruction of blood flow from the right ventricle to the pulmonary artery during systole. Most cases are congenital; many remain asymptomatic until adulthood. Signs include a crescendo-decrescendo ejection murmur. Diagnosis is by echocardiography. Symptomatic patients and those with large gradients require balloon valvuloplasty.

Etiology of Pulmonic Stenosis

Symptoms and Signs of Pulmonic Stenosis

Many children with pulmonic stenosis remain asymptomatic for years and do not present to a physician until adulthood. Even then many patients remain asymptomatic. When symptoms of pulmonic stenosis develop, they resemble those of aortic stenosis Aortic Stenosis Aortic stenosis (AS) is narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole. Causes include a congenital bicuspid valve, idiopathic... read more Aortic Stenosis (syncope, angina, dyspnea).

Visible and palpable signs reflect the effects of right ventricular (RV) hypertrophy and include a prominent jugular venous a wave (due to forceful atrial contraction against a hypertrophied RV), an RV precordial lift or heave, and a left parasternal systolic thrill at the 2nd intercostal space.

Auscultation

  • Widened 2nd heart sound (S2) and delayed pulmonic component of S2 (P2)

  • Harsh crescendo-decrescendo ejection murmur

On auscultation, the 1st heart sound (S1) is normal and the normal splitting of the S2 is widened because of prolonged pulmonic ejection (P2 is delayed). In RV failure and hypertrophy, the 3rd and 4th heart sounds (S3 and S4) are rarely audible at the left parasternal 4th intercostal space. A click in congenital PS is thought to result from abnormal ventricular wall tension. The click occurs early in systole (very near S2) and is not affected by hemodynamic changes. A harsh crescendo-decrescendo ejection murmur is audible and is heard best at the left parasternal 2nd (valvular stenosis) or 4th (infundibular stenosis) intercostal space with the diaphragm of the stethoscope when the patient leans forward.

Unlike the aortic stenosis murmur, a pulmonic stenosis murmur does not radiate, and the crescendo component lengthens as stenosis progresses. The murmur grows louder immediately with Valsalva release and with inspiration; the patient may need to be standing for this effect to be heard.

Diagnosis of Pulmonic Stenosis

  • Echocardiography

Diagnosis of pulmonic stenosis is confirmed by Doppler echocardiography, which can characterize the severity as

  • Mild: Peak gradient < 36 mm Hg (peak velocity < 3 m/second)

  • Moderate: Peak gradient 36 to 64 mm Hg (peak velocity 3 to 4 m/second)

  • Severe: Peak gradient > 64 mm Hg (peak velocity > 4 m/second)

Right heart catheterization Cardiac Catheterization Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries and veins. Cardiac catheterization... read more Cardiac Catheterization is indicated only when 2 levels of obstruction are suspected (valvular and infundibular), when clinical and echocardiographic findings differ, or before intervention is done.

Treatment of Pulmonic Stenosis

  • Sometimes balloon valvuloplasty

Prognosis of pulmonic stenosis without treatment is generally good and improves with appropriate intervention.

Treatment of pulmonic stenosis is balloon valvuloplasty, which is indicated for symptomatic patients with moderate or severe valvular stenosis and for asymptomatic patients with severe stenosis.

Percutaneous valve replacement may be offered at highly selected congenital heart centers, especially for younger patients or those with multiple previous procedures, in order to reduce the number of open heart procedures. When surgical replacement is necessary, bioprosthetic valves are preferred due to the high rates of thrombosis of right-sided mechanical heart valves; anticoagulation is temporarily required (see Anticoagulation for patients with a prosthetic cardiac valve Anticoagulation for patients with a prosthetic cardiac valve Any heart valve can become stenotic or insufficient (also termed regurgitant or incompetent), causing hemodynamic changes long before symptoms. Most often, valvular stenosis or insufficiency... read more ).

Key Points

  • Pulmonic stenosis is usually congenital, but symptoms (eg, syncope, angina, dyspnea) usually do not appear until adulthood.

  • Heart sounds include increased splitting of S2 and a harsh crescendo-decrescendo ejection murmur heard best at the left parasternal 2nd or 4th intercostal space when the patient leans forward; the murmur grows louder immediately with Valsalva release and with inspiration.

  • Balloon valvuloplasty is done for symptomatic patients and asymptomatic patients with normal systolic function and a peak gradient > 40 to 50 mm Hg.

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