eMedicine Specialties > Cardiology > Valvular Heart Disease

Pulmonic Regurgitation: Follow-up

Author: Xiushui (Mike) Ren, MD, Clinical Echocardiography Fellow, Division of Cardiology, University of California, San Francisco; Clinical Cardiology Fellow, Division of Cardiology, California Pacific Medical Center
Coauthor(s): Pablo J Saavedra, MD, Fellow, Department of Cardiology, Vanderbilt University School of Medicine; 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
Contributor Information and Disclosures

Updated: Apr 17, 2008

Follow-up

Further Inpatient Care

  • Aspects of inpatient care are primarily governed by the treatment indicated for the particular disorder that causes pulmonic regurgitation. As previously mentioned, if heart failure is present that is due to or exacerbated by pulmonic regurgitation, usual heart failure management applies.

Further Outpatient Care

  • Regurgitation may worsen with time. Therefore, periodic echocardiographic reassessment with Doppler color flow studies provides a longitudinal comparison of the progression of both the regurgitation and right ventricular size and function. In cases of significant pulmonic regurgitation, exercise capacity should be assessed and quantitated serially, observing for a change or decrease in function, the goal being to accurately assess the need and potential timing for surgical repair.

Transfer

  • Transfer requirements are the same as in heart failure.

Deterrence/Prevention

  • Specific comments on deterrence and prevention of pulmonic regurgitation in general are not found in the literature, except in the context of the specific entities, such as those listed in Causes, that can cause pulmonic regurgitation.
  • Periodic echocardiographic follow-up is appropriate when significant pulmonic regurgitation is present in order to better manage the condition over the long term and to help decide when interventions may be warranted.

Complications

  • Right-sided heart failure is a complication of volume overload of the right ventricle due to severe pulmonic regurgitation.
  • Other complications are related to the underlying disease processes resulting in pulmonic regurgitation.

Prognosis

  • In general, survival is not significantly affected by mild-to-moderate pulmonic regurgitation. If pulmonic regurgitation is severe, the right ventricle is initially able to compensate for the volume overload state, and the state may remain well compensated for years. Persistently elevated right ventricular volumes may eventually cause right ventricular dilatation, and, finally, failure.
  • As previously stated, the various disorders causing pulmonary hypertension are the most common causes of clinically significant pulmonic regurgitation. The principal prognostic indicators of mortality in pulmonic regurgitation associated with pulmonary hypertension are (1) the severity and duration of the pulmonary hypertension at the time of diagnosis and (2) the right ventricular response to the state of volume overload.
    • In all etiologies of pulmonary hypertension, early diagnosis that allows for intervention to slow or reverse the cause of pulmonary hypertension is essential, although, in many cases, diagnosis is difficult and requires a high degree of clinical suspicion.
    • In primary pulmonary hypertension, the pathologic process is often insidious, and symptoms manifest at an advanced disease state, resulting in an average survival period of 2.5 years from the time of diagnosis.
  • In congenital regurgitation of the pulmonic valve, the prognosis depends upon the initial severity, progression of the regurgitation, and the ability of the right ventricle to adapt to volume overload. Usually, the degree of regurgitation in this condition is no more than moderate, so no clinical sequelae occur. Congenital absence of the pulmonic valve, a much rarer condition, confers an increased risk of morbidity and mortality because of more severe regurgitation and usually warrants pulmonic valve replacement for improved prognosis.

Miscellaneous

Medicolegal Pitfalls

  • 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.

Special Concerns

  • 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.2
    • The current American Heart Association recommendations on prevention of invective 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.
 


More on Pulmonic Regurgitation

Overview: Pulmonic Regurgitation
Differential Diagnoses & Workup: Pulmonic Regurgitation
Treatment & Medication: Pulmonic Regurgitation
Follow-up: Pulmonic Regurgitation
References
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References

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Further Reading

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Keywords

pulmonary regurgitation, tricuspid regurgitation, pulmonic insufficiency, pulmonary insufficiency, right ventricle, right ventricular outflow, retrograde flow, right-sided volume overload, heart failure, pulmonary hypertension, dilated cardiomyopathy, connective-tissue disease, infective endocarditis, carcinoid heart disease, rheumatic heart disease, pulmonary hypertension, Graham Steell murmur, Marfan syndrome

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Contributor Information and Disclosures

Author

Xiushui (Mike) Ren, MD, Clinical Echocardiography Fellow, Division of Cardiology, University of California, San Francisco; Clinical Cardiology Fellow, Division of Cardiology, California Pacific Medical Center
Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, and American Society of Echocardiography
Disclosure: Nothing to disclose.

Coauthor(s)

Pablo J Saavedra, MD, Fellow, Department of Cardiology, Vanderbilt University School of Medicine
Pablo J Saavedra, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine
Disclosure: Nothing to disclose.

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, and Rhode Island Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

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Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marschall S Runge, MD, PhD, Charles and Anne Sanders Distinguished Professor of Medicine, Chairman of Medicine, Vice Dean for Clinical Affairs, Chairman, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine
Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association
Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, Professor and Executive Vice Chairman of Medicine
Richard A Lange, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, and Association of Subspecialty Professors
Disclosure: Nothing to disclose.

 
 
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