Pulmonic Regurgitation Differential Diagnoses
- Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA more...
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:
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 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.
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.
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.
Tetralogy of Fallot
Liu S, Xu X, Liu G, Ding X, Zhao X, Qin Y. Comparison of immediate and long-term results between the single balloon and Inoue balloon techniques for percutaneous pulmonary valvuloplasty. Heart Lung Circ. 2015 Jan. 24(1):40-5. [Medline].
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].
Harrild DM, Powell AJ, Trang TX, Geva T, Lock JE, Rhodes J, et al. Long-term pulmonary regurgitation following balloon valvuloplasty for pulmonary stenosis risk factors and relationship to exercise capacity and ventricular volume and function. J Am Coll Cardiol. 2010 Mar 9. 55(10):1041-7. [Medline].
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].
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].
Ristow B, Ahmed S, Wang L, Liu H, Angeja BG, Whooley MA. Pulmonary regurgitation end-diastolic gradient is a Doppler marker of cardiac status: data from the Heart and Soul Study. J Am Soc Echocardiogr. 2005 Sep. 18(9):885-91. [Medline].
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].
[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].
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].
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].