Pulmonic regurgitation overview: Difference between revisions

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==Cardiac MRI==
==Cardiac MRI==
Cardiac magnetic resonance(CMR) is a gold standard for assessment of morphology of the pulmonary valve, for quantification of the severity of the regurgitation and the RV systolic function. CMR is useful in quantification of the regurgitant volume and regurgitant fraction of PR by using sequences called “velocity- encoded phase-contrast images”.<ref name="pmid19164336">{{cite journal| author=Wald RM, Redington AN, Pereira A, Provost YL, Paul NS, Oechslin EN et al.| title=Refining the assessment of pulmonary regurgitation in adults after tetralogy of Fallot repair: should we be measuring regurgitant fraction or regurgitant volume? | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 3 | pages= 356-61 | pmid=19164336 | doi=10.1093/eurheartj/ehn595 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19164336  }} </ref> CMR is useful for evaluating pulmonary regurgitant fraction, RV end-diastolic and end- systolic volumes, and RV ejection fraction. CMR is the diagnostic modality preffered to determine the requirement of reintervention in patients with repaired tetralogy of Fallot and to assess the ventricular function and dimensions.
==Pulmonary angiography==
==Pulmonary angiography==
==Treatment==
==Treatment==

Revision as of 15:47, 4 January 2017

Pulmonic regurgitation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential diagnosis

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Electrocardiogram

Chest X-Ray

Echocardiography

Cardiac MRI

Severity Assessment

Treatment

Medical Therapy

Surgical therapy

Follow up

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]

Overview

Pulmonary valve regurgitation is a condition where the pulmonary valve is not strong enough to prevent backflow into the right ventricle. Nearly all individuals have physiologic (trace-to-mild) pulmonic regurgitation, and the incidence increases with advancing age. Hence, there is a backward flow of blood from the pulmonary artery, through the pulmonary valve, and into the right ventricle of the heart during diastole.

Historical perspective

The pulmonary valve and its function of allowing blood to the lungs for nourishment was first described by Hippocrates. Erasistratus, mentioned the involvement of the pulmonary valve in the unidirectional flow. Realdo Colombo described the pulmonary circulation for the first time.[1]

Classification

Pulmonary valve regurgitation may be classified according to pulmonary valve morphology and severity of the disease. According to the pulmonary valve morphology, it may be classified into primary and secondary or functional regurgitation. Severity of disease may classify into mild, moderate and severe disease.[2][3][4]

Pathophysiology

Pathophysiologic mechanism of pulmonic regurgitation include right ventricular overload resulting in right ventricular remodelling and progressive decline in function. The rate of decline in right ventricular systolic function is affected by associated conditions such as peripheral pulmonary artery stenosis and pulmonary hypertension which further increase the severity of pulmonary regurgitation.[5]

Causes

A small percentage of pulmonic regurgitation is normal and occasionally can be heard in thin subjects. The most common causes of pulmonary regurgitation are following repair of tetralogy of Fallot and pulmonary stenosis.[6][7][8][9]

Differential Diagnosis

The diseases which may present with overlapping symptoms as pulmonic regurgitation may include aortic regurgitation, tricuspid regurgitation, left to right shunting, right ventricular cardiomyopathy, pulmonary hypertension, infective endocarditis, carcinoid heart disease, syphilis and marfan syndrome.[10][11][12]

Epidemiology and demograpics

The prevalence of mild pulmonary regurgutation is present in 40% to 78% of patients with normal pulmonary valve anatomy.[13][14] There is increased prevalence of pulmonary regurgitation with increasing age.

Risk factors

The risk factors of pulmonic regurgitation may include pulmonary hypertension, surgical repair of teratology of fallot, endocarditis, left sided heart disease, previous ross procedure, collagen vascular disease, and involving the main pulmonary artery.[15][16][2][17]

Screening

There are no specific screening recommendations for patients with pulmonary regurgitation.[18]

Natural history, complications and prognosis

Majority of patients with mild PR are asymptomatic and have a benign course, not progressing to chronic PR. Patients tolerate severe chronic PR for a long period of time and begin to develop symptoms when the right ventricle function begins to decline. Chronic severe PR leads to progressive dilation and systolic dysfunction of the right ventricle resulting in symptoms.[19] Complications which may result from pulmonary regurgitation include progressive right ventricular dilatation, heart failure, tricuspid regurgitation, ventricular arrythmias, and sudden cardiac death. Symptomatic patients are treated with pulmonary valve replacement and have a good prognosis.[20]

Diagnosis

The diagnosis of pulmonic regurgitation may include detailed history, physical examination and diagnostic tests such as EKG, echocardiography, chest x ray and cardiac MRI.

History and symptoms

Clinical presentation of pulmonary regurgitation varies on the severity of the regurgitation and right ventricular dysfunction. Isolated pulmonary regurgitation is usually asymptomatic. However, patients with chronic PR may present with ankle edema, swelling of feet or legs, dyspnea on exertion, fatigue, hemoptysis, nocturnal cough and palpitations.[19][21]

Physical examination

Physical examination findings of pulmonary regurgitation includes increased JVP, prominent "a" wave, "v" wave in the neck. A palpable impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation. On auscultation, it may be associated with wide splitting of S2 with right sided S3 accentuated with respiration. Murmer of pulmonic regurgitation may vary depending on the underlying cause.[22][23]

Electrocardiogram

EKG findings in patients wit chronic PR may be non specific. However, in patients with tetrology of fallot may show increased QRS duration with widened QRS complex. It may reflect the severity of PR and right ventricular dilation predisposing the patient to develop arrythmias. [24][25]

Chest x ray

Chest x ray may not be required for the diagnosis of pulmonic regurgitation. However, lateral and PA view of chest radiograph may help determining the right ventricular enlargement. Right atrial enlargement may also be seen in patients with concomitant tricuspid regurgitation.[26]

Echocardiography

Echocardiography is the initial test which may be used to assess pulmonary valve morphology, RVOT anatomy, and to identify the presence and quantify the severity of PR. Different modes of echocardiography may be used to improve the accuracy of findings and assess the severity of the disease which include colour flow doppler, flow convergence method, pulsed doppler, spectral doppler and exercise echocardiography.[27][4][28]

Cardiac MRI

Cardiac magnetic resonance(CMR) is a gold standard for assessment of morphology of the pulmonary valve, for quantification of the severity of the regurgitation and the RV systolic function. CMR is useful in quantification of the regurgitant volume and regurgitant fraction of PR by using sequences called “velocity- encoded phase-contrast images”.[29] CMR is useful for evaluating pulmonary regurgitant fraction, RV end-diastolic and end- systolic volumes, and RV ejection fraction. CMR is the diagnostic modality preffered to determine the requirement of reintervention in patients with repaired tetralogy of Fallot and to assess the ventricular function and dimensions.

Pulmonary angiography

Treatment

Medical therapy

Surgical therapy

Follow up

References

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  17. Rebergen SA, Chin JG, Ottenkamp J, van der Wall EE, de Roos A (1993). "Pulmonary regurgitation in the late postoperative follow-up of tetralogy of Fallot. Volumetric quantitation by nuclear magnetic resonance velocity mapping". Circulation. 88 (5 Pt 1): 2257–66. PMID 8222120.
  18. Mercer-Rosa L, Yang W, Kutty S, Rychik J, Fogel M, Goldmuntz E (2012). "Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: a comparative analysis of echocardiography and magnetic resonance imaging". Circ Cardiovasc Imaging. 5 (5): 637–43. doi:10.1161/CIRCIMAGING.112.972588. PMC 3476467. PMID 22869820.
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  20. Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY; et al. (2012). "Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement". J Am Coll Cardiol. 60 (11): 1005–14. doi:10.1016/j.jacc.2012.03.077. PMID 22921969.
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  26. https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017
  27. Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM; et al. (2014). "Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology". J Am Soc Echocardiogr. 27 (2): 111–41. doi:10.1016/j.echo.2013.11.009. PMID 24468055.
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  29. Wald RM, Redington AN, Pereira A, Provost YL, Paul NS, Oechslin EN; et al. (2009). "Refining the assessment of pulmonary regurgitation in adults after tetralogy of Fallot repair: should we be measuring regurgitant fraction or regurgitant volume?". Eur Heart J. 30 (3): 356–61. doi:10.1093/eurheartj/ehn595. PMID 19164336.

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