Pulmonic regurgitation physical examination

Pulmonic regurgitation Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]; Aysha Anwar, M.B.B.S[3]

Physical Examination

Neck

• Increased JVP
• Prominent "a wave" may be present
• Prominent "v wave" may be present in presence of tricuspid regurgitation

Palpation

• A palpable impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation.

Auscultation

Heart Sounds

• Pulmonic regurgitation is associated with wide splitting of S₂.
• P2 is accentuated because of presence of pulmonary regurgitation. In case of, absence of pulmonic valves (congenital or secondary to surgical resection), P2 is inaudible.
• A right-sided S₃ may be audible and may also be accentuated with inspiration.
• Likewise, a right-sided S4 may also be audible and accentuated with inspiration.

Murmur

• Murmur of residual pulmonic regurgitation after Tetralogy of Fallot repair:
  • It is a low-pitched and soft murmur.
  • Best heard along the second or third intercostal spaces adjacent to the left sternal border.
  • It is accentuated by squatting and inspiration.
  • It is made softer by Valsalva maneuvers or expiration.

• Murmur of pulmonic regurgitation associated with Pulmonic hypertension:
  • When the pulmonary artery systolic pressure exceeds 60 mm Hg, dilatation of the pulmonary artery ring may then result in Graham-Steell's murmur.
  • It is a high-pitched, "blowing", early diastolic decrescendo murmur like that of aortic regurgitation.
  • Best heard along the left parasternal region.
  • It is accentuated by inspiration.

Sources

• Bouzbas, B., Kilner, P. J., & Gatzoulis, M. A. (2005). Pulmonary regurgitation: not a benign lesion. European Heart Journal, 433-9.
• Wessel, H. U., Cunningham, W. J., Paul, M. H., Bastanier, C. K., Muster, A. J., & Idriss, F. S. (1980). Exercise performance in tetralogy of Fallot after intracardiac repair. Journal of Thoracic and Cardiovascular Surgery, 582-93.
• Shimazaki, Y., Blackstone, E. H., & Kirklin, J. W. (1984). The natural history of isolated congenital pulmonary valve incompetence: surgical implications. Journal of Thoracic and Cardiovascular Surgery, 257-9.
• Geva, T., Sandweiss, B. M., Gauvreau, K., Lock, J. E., & Powell, A. (2004). Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. Journal of the American College of Cardiology, 1068-74.