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Pulmonic Stenosis Differential Diagnoses

  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Dec 22, 2014
 
 

Diagnostic Considerations

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

  • Congenital heart abnormality (see Causes)
  • Rheumatic valvular heart disease
  • Carcinoid heart disease

Pulmonic stenosis in pregnancy

Valvular heart disease, including PS, should warrant follow-up care by a high-risk obstetrics team. The hemodynamic changes in pregnancy—which include increase in plasma volume proportionally greater than red blood cell volume, increase in cardiac stroke volume, decrease in systemic vascular resistance, decrease in pulmonary vascular resistance with a drop in pulmonary pressures, and decrease in venous return that is more marked in the third trimester—can exacerbate the symptoms of PS.

In general, pregnancy is tolerated well by individuals who have asymptomatic PS before conception, even if the degree of stenosis is severe.

When symptoms are referable to PS, they are similar to those of individuals who are not pregnant and symptomatic. The symptoms of healthy pregnancy can resemble those of PS, including exertional fatigue, dyspnea, orthopnea, presyncope, and, rarely, frank syncope. Palpitations due to arrhythmias have been noted to be more common in those with PS.

Mild PS produces a murmur similar to that of the benign flow murmur of pregnancy, which typically increases in intensity as the stroke volume is augmented. During the physical examination, this murmur can be distinguished from the flow murmur of pregnancy by noting a prominent jugular venous a wave, an RV lift, a systolic thrill over the pulmonic area, a pulmonic ejection click, and a diminished or absent P2. ECG and echocardiographic evaluation are essential in confirming clinical suspicion. Fetal echocardiography is indicated in patients with PS or tetralogy of Fallot.

Treatment in pregnancy

Avoidance of vigorous exercise is recommended, especially during the second half of pregnancy in patients with moderate-to-severe gradients.

Balloon valvuloplasty is recommended in nonpregnant patients when the gradient across the right ventricular outflow track is greater than 50 mm Hg at rest or when the patient is symptomatic.

If severe PS is detected during pregnancy, percutaneous balloon valvuloplasty to relieve the obstruction usually can be accomplished safely, obviating the need to terminate the pregnancy.

Arrhythmias are treated according to the severity of symptoms.

Considerations for labor and delivery

Patients who are asymptomatic during pregnancy generally tolerate labor and delivery well.

For more severe valvular disease, a high-risk obstetrics team along with a cardiology consultation may be required to manage deliveries.

Antibiotic prophylaxis generally is not recommended for cesarean delivery and is considered optional in women with PS that is associated with complex congenital heart disease.

See AHA Guidelines on prevention of Infective Endocarditis.

Pulmonic stenosis in athletes

Athletes with mild PS gradients (ie, < 50 mm Hg) have no activity limitations.

Those with more severe PS can participate in low-intensity competitive sports; their treatment should be directed by the criteria discussed in Treatment.

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.

Additional Contributors

Park W Willis IV, MD Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Nothing to disclose.

References
  1. [Guideline] Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008 Dec 2. 118(23):e714-833. [Medline].

  2. Odenwald T, Taylor AM. Pulmonary valve interventions. Expert Rev Cardiovasc Ther. 2011 Nov. 9(11):1445-57. [Medline].

  3. [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: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10. 129(23):e521-643. [Medline].

  4. [Guideline] Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012 Oct. 33(19):2451-96. [Medline].

  5. Hameed AB, Goodwin TM, Elkayam U. Effect of pulmonary stenosis on pregnancy outcomes--a case-control study. Am Heart J. November 2007. 154:852. [Medline]. [Full Text].

  6. Shaath G, Mutairi MA, Tamimi O, Alakhfash A, Abolfotouh M, Alhabshan F. Predictors of re-intervention in neonates with critical pulmonary stenosis or pulmonary atresia with intact ventricular septum. Catheter Cardiovasc Interv. 2011 Sep 27. [Medline].

  7. Zdradzinski MJ, Qureshi AM, Stewart R, et al. Comparison of long-term postoperative sequelae in patients with tetralogy of Fallot versus isolated pulmonic stenosis. Am J Cardiol. 2014 Jul 15. 114(2):300-4. [Medline]. [Full Text].

 
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Pulmonic stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a parasternal short axis view of the thickened pulmonary valve.
Pulmonic stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a Doppler scan of the peak velocity (5.2 m/s) and gradients (peak 109 mm Hg, mean 65 mm Hg) across the valve.
Pulmonic stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows that moderately severe pulmonary insufficiency (orange color flow) is also present.
This video is an echocardiogram of a patient with severe pulmonic stenosis. The first segment shows the parasternal short axis view of the thickened pulmonary valve. The second segment shows the presence of moderate pulmonary insufficiency (orange color flow).AV=Aortic valve, PV=Pulmonary valve, PA=Pulmonary artery, PI=Pulmonary insufficiency
 
 
 
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