Approach Considerations
Pulmonary or pulmonic regurgitation (PR) is seldom severe enough to warrant special treatment because the right ventricle normally adapts to low-pressure volume overload without difficulty. High-pressure volume overload leads to right-sided heart strain and, ultimately, heart failure.
Treatment for PR is usually focused on the underlying cause that created the valve problem (eg, pulmonary hypertension). Underlying etiologies causing severe PR, whether congenital or acquired, must be treated to prevent or reverse right-sided heart strain and failure that may further complicate the clinical picture.
If pulmonary hypertension is identified with PR, determining the etiology is essential to institute appropriate therapy as expeditiously as possible. For example, primary pulmonary hypertension, secondary pulmonary hypertension due to thromboembolism, severe mitral stenosis, and pulmonary carcinomatosis can all manifest as severe pulmonary hypertension with PR. A discussion of therapeutic interventions in pulmonary hypertension by etiology is beyond the scope of this article. Refer to the articles for each entity under Differentials for a detailed discussion of treatment options.
The need for surgical replacement of the pulmonary valve is very rare.
Transfer requirements are the same as in heart failure.
Consider consultation with cardiologists for patients with right-sided heart failure in the presence of severe PR.
Medical Care
No aspect of medical management of heart failure is uniquely applicable to pulmonary or pulmonic regurgitation (PR), and the discussion of management of right-sided heart failure is beyond the scope of this article. In general, similar approaches to those used in the treatment of patients with left-sided congestive heart failure can be useful. In some circumstances, such as in patients with pulmonary hypertension, vasodilator therapies must be very carefully considered and monitored. In addition, therapies aimed toward the underlying etiology may also reduce PR (see Heart Failure).
Aspects of inpatient care are primarily governed by the treatment indicated for the particular disorder that causes PR. As previously mentioned, if heart failure is present that is due to or exacerbated by PR, usual heart failure management applies.
The American Heart Association and the American College of Cardiology (AHA/ACC) continually updates their guidelines on the management of patients with valvular heart disease. [1, 16]
As noted earlier, the AHA 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, PR 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. [16, 17, 18]
Surgical Care
When right-sided heart failure due to pulmonary or pulmonic regurgitation (PR) from an abnormal pulmonic valve cannot be ameliorated by medical management, appropriate options include surgical reconstruction or replacement of the pulmonic valve, preferably with a bioprosthetic valve. Bioprosthetic valves with a logevity up to approximately 15 years after implantation are usually preferred over mechanical valve protheses. [14] Continuing advances in technology include investigational novel valves for use in larger, nonconduit, outflow tracts (vs fixed-dimension conduits) and the addition of a hybrid surgical and transcatheter approach to pulmonary valve implantation. [25]
Although congenital PR is usually well tolerated, the much more rare congenital absence of the pulmonic valve usually requires pulmonic valve replacement (PVR). Young adults with PVR are likely to require further surgery because protheses have a limited life span.
Patients should be considered for surgery when both greater than moderate PR and progressive right ventricular (RV) dilatation are present. Delaying surgery may lead to irreverisble RV dysfunction. When PVR is performed, there is reduction of RV size and improved function. However, RV function may not recover in PVR that is performed late.
The following are indications for surgical PVR [26] :
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Severe, symptomatic PR
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Asympatomatic severe PR with severe RV dilatation and/or dysfunction or symptomatic atrial and/or ventricular arrythmias; dysfunction on cardiac magnetic resonance imaging with RV end-diastolic volume above 150 mL/m 2, an end-systolic volume over 80 mL/m 2, and an ejection fraction below 47%
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Severe PR and progressive tricuspid valve regurgitation
Percutaneous implantation
Relatively recently, percutaneous intervention for dysfunctional RV outflow tract conduits has become available. The intermediate-term results have shown that percutaneous bioprosthetic valve implantation is a reasonable option for patients with dysfunctional RV outflow tract conduits, especially those with high surgical risk. Freedom from valve dysfunction or reintervention following percutaneous bioprosthetic valve placement was 93.5% at 1 year. [27]
Diet and Activity
Diet
No specific dietary recommendations exist for pulmonary or pulmonic regurgitation (PR). However, patients who have heart failure symptoms may benefit from a salt-restricted diet.
Activity
Because PR is usually of a mild to moderate degree, restriction of athletic activities is unnecessary. Follow-up echocardiographic studies can provide data to assess for changes in PR and right ventricular functional status to more objectively base activity-limitation recommendations.
Prevention
Patients with underlying conditions such as mtiral stenosis, left ventricular dysfunction, and pulmonary hypertension should be treated.
Specific comments on deterrence and prevention of pulmonary or pulmonic regurgitation (PR) in general are not found in the literature, except in the context of the specific entities, such as those listed under Etiology, that can cause this condition.
Periodic echocardiographic follow-up is appropriate when significant PR is present for clinicians to better manage the condition over the long term and to help decide when interventions may be warranted.
Long-Term Monitoring
Patients with moderate or severe pulmonary or pulmonic regurgitation (PR) should be seen annually to observe for changes in symptoms and for echocardiography. Adults with repaired tetralogy of Fallot should also be evaluated annually.
Following pulmonic valve repair, patients require an inital transthoracic echocardiogram to assess baseline valve hemodynamics. Anticoagulation is required for all patients with a mechanical valve prosthesis. For those with a bioprosthesis, administration of 3 to 6 months of oral anticoagulation is recommended. [28]
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 PR, 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.
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Continuous-wave signal of transpulmonary flow in severe pulmonary regurgitation. Courtesy of Wikimedia Commons [AMC Echolab, AMC, The Netherlands].
