ADULT ECHOCARDIOGRAPHY Lesson Six The Pulmonic Valve Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT, N.P.

Pulmonic Stenosis Etiology Congenital (most common) Rheumatic (rare) Carcinoid Peripheral (PPS-Junction of the R & L Pas) Infundibular (subvalvular) Prosthetic valve dysfunction

Pathophysiology Systolic pressure overload leads to right ventricular hypertrophy (RVH) Regional hypertrophy may lead to infundibular stenosis Commonly associated with other congenital malformations (VSDs, ASDs, tetralogy of Fallot) RV chamber size usually normal, right atrium will enlarge Increased risk for endocarditis

Physical Signs Dyspnea on exertion Systolic ejection murmur left upper sternal border (LUSB) Pulmonary ejection sound, decreased/delayed P2 Increased A wave or jugular venous pulsation (JVP) Sustained RV impulse at mid-lower left sternal border (LSB)

ECHO M-mode may show an increase in the pulmonic “a” dip of more than 7mm (useful for severe PS only) Valvular thickening and systolic doming (2-D) Right ventricular hypertrophy Post-stenotic dilatation of the pulmonary artery (PA) Narrowing of RVOT in infundibular PS (subvalvular in RVOT)

NOTE: Noonan Syndrome Know that PS dose NOT cause pulmonary Classified as a cardiofacial syndrome with PS, HCM and ASD (30%) Know that PS dose NOT cause pulmonary hypertension

M-mode of pulmonic valve showing early systolic closure and an absent A wave in a patient with severe pulmonary hypertension

Doppler Increased velocity and turbulence at level of obstruction (valvular, subvalvular, or supravalvular) Used pulsed/color flow Doppler to locate level of obstruction Check for coexisting pulmonic regurgitation Measure peak and mean gradients (parasternal short-axis AoV level and RVOT long-axis are best)

The normal Pulmonary Velocity is about 1 m/sec.

NOTE: If you are unable to obtain a PS gradient from the parasternal window, try the subcostal short-axis view.

AHA/ACC Guidelines for Pulmonary Stenosis Severity: Mild Moderate Severe Peak Velocity m/s <3.0 3.0-4.0 >4.0 Peak Gradient mm/Hg <36 36-64 >64

PS Gradients vary with Respiration

End Lesson Six Next: The Mitral Valve