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Pulmonic Regurgitation Differential Diagnoses

  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Feb 17, 2015
 
 

Diagnostic Considerations

As with any cardiovascular diagnosis, it is important to document the presence and extent of pulmonic regurgitation, the treatment options considered and undertaken (including antibiotic prophylaxis for dental and other procedures), and the plans for follow-up care.

Other conditions to be considered in patients with suspected pulmonic regurgitation include the following:

  • Marfan syndrome
  • Rheumatic heart disease
  • Carcinoid heart disease
  • Aortic insufficiency: The Graham Steell murmur of pulmonary hypertension is identical in quality to that of the early diastolic murmur in aortic insufficiency. They must be differentiated.

Pregnancy

Pregnancy is usually well tolerated in patients with pulmonic regurgitation, including those who have had surgical repairs for tetralogy of Fallot, except when right-sided heart failure is present that cannot be medically controlled.

Infective endocarditis

Pulmonic valve endocarditis is almost always associated with immunosuppressed states, intravenous drug abuse, and/or congenital heart disease. The risk of endocarditis is thought to chiefly depend upon 2 factors: the presence of high-velocity flow that injures endothelium by shear forces or jet impact and exposure to infective organisms. In a series of 186 patients from a congenital heart disease registry with varying degrees of pulmonary and/or tricuspid regurgitation and normal pulmonic and tricuspid valves, the investigators observed that the occurrence of pulmonic and tricuspid valve endocarditis was extremely low. The study, however, was not large enough to resolve the question of endocarditis risk in this group, and the authors still advised antibiotic prophylaxis against endocarditis.[10]

The American Heart Association recommendations on prevention of infective endocarditis do not support the necessity for antibiotic prophylaxis in pulmonic regurgitation for otherwise structurally normal pulmonic valves, especially if no diastolic murmur is audible (see Infective Endocarditis). However, pulmonic regurgitation in congenital heart malformations, acquired valvular dysfunction as in rheumatic heart disease, complex cyanotic heart disease, prosthetic valves, and prior bacterial endocarditis comprise moderate-to-high–risk conditions that warrant antibiotic prophylaxis.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Xiushui (Mike) Ren, MD Cardiologist, The Permanente Medical Group; Associate Director of Research, Cardiovascular Diseases Fellowship, California Pacific Medical Center

Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Lauralyn B Cannistra, MD, FACC Director of Echocardiography Lab and Cardiac Rehabilitation, Assistant Professor, Department of Medicine, Memorial Hospital of Rhode Island, Brown University School of Medicine

Lauralyn B Cannistra, MD, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Anesthesiologists, American Society of Echocardiography, Rhode Island Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Marschall S Runge, MD, PhD Charles and Anne Sanders Distinguished Professor of Medicine, Chairman, Department of Medicine, Vice Dean for Clinical Affairs, University of North Carolina at Chapel Hill School of Medicine

Marschall S Runge, MD, PhD is a member of the following medical societies: American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Texas Medical Association, Southern Society for Clinical Investigation, American Federation for Clinical Research, Association of Professors of Medicine, Association of Professors of Cardiology, American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Medical Research, American Heart Association

Disclosure: Received honoraria from Pfizer for speaking and teaching; Received honoraria from Merck for speaking and teaching; Received consulting fee from Orthoclinica Diagnostica for consulting.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Pablo J Saavedra, MD, to the development and writing of this article.

References
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  2. Eyskens B, Brown SC, Claus P, Dymarkowski S, Gewillig M, Bogaert J, et al. The influence of pulmonary regurgitation on regional right ventricular function in children after surgical repair of tetralogy of Fallot. Eur J Echocardiogr. 2010 Jan 19. [Medline].

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  4. Pellikka PA, Tajik AJ, Khandheria BK, Seward JB, Callahan JA, Pitot HC, et al. Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Circulation. 1993 Apr. 87(4):1188-96. [Medline].

  5. Kitagawa A, Oka N, Kimura S, et al. Clinical utility of the plasma brain natriuretic peptide level in monitoring tetralogy of Fallot patients over the long term after initial intracardiac repair: considerations for pulmonary valve replacement. Pediatr Cardiol. 2014 Dec 12. [Medline].

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  7. Ristow B, Ali S, Ren X, Whooley MA, Schiller NB. Elevated pulmonary artery pressure by Doppler echocardiography predicts hospitalization for heart failure and mortality in ambulatory stable coronary artery disease: the Heart and Soul Study. J Am Coll Cardiol. 2007 Jan 2. 49(1):43-9. [Medline].

  8. [Guideline] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10. 63(22):2438-88. [Medline].

  9. McElhinney DB, Hellenbrand WE, Zahn EM, Jones TK, Cheatham JP, Lock JE, et al. Short- and Medium-Term Outcomes After Transcatheter Pulmonary Valve Placement in the Expanded Multicenter US Melody Valve Trial. Circulation. 2010 Aug 3. 122(5):507-16. [Medline].

  10. Dodo H, Perloff JK, Child JS, et al. Are high-velocity tricuspid and pulmonary regurgitation endocarditis risk substrates?. Am Heart J. 1998 Jul. 136(1):109-14. [Medline].

 
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