Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pulmonic Stenosis Workup

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

Plain Chest Radiography

A characteristic radiographic finding, even with mild valvular pulmonic stenosis (PS), is prominence of the main, right, or left pulmonary arteries caused by poststenotic dilatation.

The intrapulmonary vasculature usually appears normal, even in severe PS.

In critical PS, the pulmonary vasculature may appear decreased if significant right-to-left shunting occurs through a patent foramen ovale or atrial septal defect or if severe unilateral pulmonary artery branch obstruction is present.

The overall heart size usually is normal unless RV failure or tricuspid regurgitation develops.

A prominent right heart border suggesting right atrial enlargement may be present in as many as 50% of affected individuals.

Next

Echocardiography

Echocardiography provides a definitive confirmation of the diagnosis of PS. Both 2-dimensional and Doppler techniques should be used to comprehensively evaluate the pulmonic valve.

Using 2-dimensional imaging, thickening of the valves, characteristic doming of nondysplastic valves, and right ventricular (RV) hypertrophy can be noted readily (see image below). RV size and systolic function, right atrial (RA) size, and pulmonary artery dimensions can be quantified in most patients.

Pulmonic stenosis. Echocardiogram of a patient wit Pulmonic stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a parasternal short axis view of the thickened pulmonary valve.

Color Doppler aids in both defining high velocity jets and localizing their origin. Pulsed waved Doppler (placed just proximal to the site of obstruction) and continuous wave Doppler are used to measure jet velocity, which can be converted to pressure gradient using the modified Bernoulli equation. Normally, no systolic gradient is present across the pulmonic valve. With PS, however, the RV systolic pressure increases and a pressure gradient occurs between the RV and pulmonary artery. Doppler studies of the stenotic valve can determine the severity of the gradient (see image below).

Pulmonic stenosis. Echocardiogram of a patient wit 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.

The pulmonary valve area of a healthy adult is 2.0 cm2/m2 of body surface area. Mild valvular PS is defined by a valve area larger than 1 cm2 and a transvalvular pressure gradient of less than 50 mm Hg. Moderately severe PS occurs if the valve area is 0.5-1.0 cm2, with a transvalvular pressure gradient between 50 and 75 mm Hg. Severe PS is defined by a valve area smaller than 0.5 cm2 and a transvalvular pressure gradient greater than 75 mm Hg.

RV hypertrophy with asymmetric septal hypertrophy may be present. In addition, restrictive physiology can be demonstrated by Doppler interrogations of tricuspid inflow, hepatic vein flow, and Doppler tissue imaging. A restrictive RV pattern is associated with worse RV systolic function and worse exercise tolerance.

Doppler evidence of right-sided pressures approaching or exceeding systemic pressures or a 2-dimensional echocardiogram demonstrating paradoxical septal motion during systole with reversal of the usual right convex curvature of the interventricular septum is an indication for therapeutic intervention (see image and video below).

Pulmonic stenosis. Echocardiogram of a patient wit 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
Previous
Next

Cardiac Catheterization and Pulmonary Angiography

Cardiac catheterization generally is not needed to verify the findings of noninvasive tests, except when a significant discrepancy is noted between clinical findings and echocardiographic findings. When performed, cardiac catheterization can diagnose PS by a pressure gradient from the pulmonary artery to the RV on "pull-back" of the pulmonary artery catheter. Cardiac catheterization may be useful in assessing the presence of concomitant congenital abnormalities.

In the case of isolated PPS, pulmonary angiography may be needed to establish the diagnosis.

Previous
Next

Electrocardiography

The degree of (right) ventricular hypertrophy on the ECG is largely correlated directly with the severity of PS.

With mild PS, 50% of patients have a normal ECG tracing or only mild right-axis deviation.

With moderately severe PS, right-axis deviation and increased R-wave amplitude in V1 are seen.

Severe PS is associated with extreme right-axis deviation, a dominant R wave in AVR, and a prominent R wave (>20 mm) in V1.

Previous
 
 
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].

 
Previous
Next
 
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
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.