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Pulmonic Stenosis Treatment & Management

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

Surgical Care

Traditionally, pulmonic stenosis (PS) was treated by surgical valvotomy. Since its introduction in 1982, however, percutaneous balloon valvuloplasty has become the initial intervention in children, adolescents, and adults with congenital valvar PS. Balloon valvuloplasty should be considered in any patient with a transvalvular pressure gradient greater than 50 mm Hg.

Occasionally, balloon valvuloplasty is not successful. These patients tend to have valvular dysplasia (eg, Noonan syndrome) or a hypoplastic pulmonic valve annulus and, therefore, may require surgical valvotomy.

Pulmonary artery balloon angioplasty with or without placement of an expandable metal stent can be used to treat supravalvular PS and PPS. Expandable metal stents can overcome an obstruction successfully; however, the need for stent reexpansion as the individual grows remains problematic.

The American Heart Association/American College of Cardiology[3] and the European Society of Cardiology[4] have published guidelines on the management of patients with valvular heart disease.

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Activity

Pregnancy

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

One study found that pregnant patients with PS had favorable outcomes and low maternal and fetal complications. This is in contrast to left heart obstructive lesions such as aortic and mitral stenosis.[5]

Athletes

Athletes with mild PS and gradients less than 50 mm Hg have no activity limitations. Those with more severe PS can participate in low-intensity competitive sports.

For more details, see Diagnostic Considerations.

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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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