Pulmonic Valve



Pulmonic Valve


Anupama Rao





High-Yield Findings



  • Pulmonic stenosis (PS) is usually found in conjunction with congenital heart disease


  • PS may occur at the valvular, subvalvular, or supravalvular levels


  • Carcinoid disease is a common cause of acquired pulmonic valve disease and can cause both stenosis and regurgitation


  • Severe pulmonic regurgitation (PR) is most often seen in the setting of pulmonary hypertension or in patients with repaired tetralogy of Fallot


  • With severe PR, CW Doppler shows rapid deceleration of the PR jet. Presystolic forward flow can be seen with severe PR due to premature opening of PV due to high RVEDP



Key Views

TTE



  • PLAX and PSAX views tilted toward RV outflow tract (RVOT)


  • Subcostal view

TEE



  • High esophageal view at 0 to 20 degrees


  • Mid esophageal level at 50 to 90 degrees (RV inflow/outflow view)


  • Deep transgastric view 110 to 140 degrees


Anatomy

The pulmonic valve is a semi-lunar valve regulating flow between the right ventricle and the pulmonary artery. It consists of three leaflets projecting into the pulmonary artery, namely the anterior, right, and left cusps. The leaflets are attached at their base to the valve annulus, a scalloped ring of fibrous tissue.


Physiology

The pulmonic valve opens in ventricular systole when pressure in the right ventricle exceeds that of the pulmonary artery. The valve closes at the end of systole when the pressure in the pulmonary artery is greater than in the right ventricle. Closure of the pulmonic valve produces the P2 component of the second heart sound.



Pulmonic Stenosis

Pulmonic stenosis involves fixed or dynamic obstruction of blood flow from the right ventricle to the pulmonary vasculature. It is mostly seen in the setting of congenital heart disease.


Etiology








Congenital heart disease (most common)

  • Tetralogy of Fallot
  • Transposition of great arteries
  • Isolated valvular pulmonic stenosis
  • Noonan syndrome (60%) with PS
Other causes (rare)

  • Carcinoid syndrome
  • Rheumatic heart disease
  • External compression by sinus of Valsalva aneurysms, aortic graft aneurysms or large mediastinal tumors
  • Cardiac tumors compressing RVOT

Obstruction can arise from the subvalvular, valvular, or supravalvular regions.



  • Valvular: Dysplastic, bicuspid, or unicuspid valves


  • Subvalvular: Narrowing of infundibulum/RVOT, which can be seen in tetralogy of Fallot or double-chambered right ventricle, congenital VSD, severe right ventricular hypertrophy, external compression by mass or tumor


  • Supravalvular: Obstruction at the level of the main pulmonary artery or its more distal branches (e.g., Noonan’s syndrome and Williams syndrome) (see Fig. 11-3)


2D Findings



  • Right ventricular hypertrophy (normal thickness of the RV is <5 mm at end-diastole) (Fig. 11-1A)


  • Right ventricular enlargement (Fig. 11-1B and C)


  • Thickened pulmonic valve leaflets with systolic doming


  • Post-stenotic dilatation of pulmonary artery


M-Mode

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Oct 20, 2016 | Posted by in CARDIOLOGY | Comments Off on Pulmonic Valve

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