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

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

3. 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

4. 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)

5. 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)

6. 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

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

8. 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)

9. The normal Pulmonary Velocity is about 1 m/sec.

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

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

13. PS Gradients vary with Respiration

14. End Lesson Six
Next: The Mitral Valve