Valvar Pulmonary Stenosis Guidelines

Updated: Dec 28, 2020
  • Author: Syamasundar Rao Patnana, MD; Chief Editor: Howard S Weber, MD, FSCAI  more...
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Guidelines

Guidelines Summary

2018 American Heart Association/American College of Cardiology (AHA/ACC) guidelines

Class I and IIa recommendations for valvar pulmonary stenosis [47]

Balloon valvuloplasty is recommended in adults with moderate or severe valvar pulmonary stenosis and otherwise unexplained symptoms of heart failure, cyanosis from interatrial right-to-left communication, and/or exercise intolerance (class I, level of evidence [LOE]: B).

Surgical repair is recommended in adults with moderate or severe valvular pulmonary stenosis and otherwise unexplained symptoms of heart failure, cyanosis, and/or exercise intolerance who are not candidates for balloon valvuloplasty or for whom balloon valvuloplasty was unsuccessful (class I, LOE: B). 

In asymptomatic adults with severe valvar pulmonary stenosis, intervention is reasonable (class IIa, LOE: C).

Class I and IIb recommendations for isolated pulmonary regurgitation (PR) after repair of pulmonary stenosis [47]

Pulmonary valve replacement is recommended in symptomatic patients with moderate or greater PR resulting from treated isolated pulmonary stenosis, with right ventricular (RV) dilation or RV dysfunction (class I, LOE: C).

For asymptomatic patients with residual PR as a result of treatment of isolated pulmonary stenosis with a dilated RV, serial follow-up is recommended (class I, LOE: C).

In asymptomatic patients with moderate or greater PR from treatment of isolated pulmonary stenosis with progressive RV dilation and/or RV dysfunction, pulmonary valve replacement may be reasonable (class IIb, LOE: C).

2020 ESC guidelines

The European Society of Cardiology (ESC) updated their 2010 guidelines on the management of adult congenital heart disease (ACHD) in 2020. [48, 49]  Their class I and III recommendations for RV outflow tract obstruction (OTO) are outlined below.

In valvular pulmonary stenosis, balloon valvuloplasty is the intervention of choice, if anatomically suitable.

As long as no valve replacement is required, RVOTO intervention at any level is recommended regardless of symptoms when the stenosis is severe (Doppler peak gradient >64 mmHg).

If surgical valve replacement is the only option, it is indicated in (1) symptomatic patients with severe stenosis; or (2) asymptomatic patients with severe stenosis in the presence of ≥1 of the following:

  • Objective decrease in exercise capacity
  • Falling RV function and/or progression of tricuspid regurgitation (TR) to at least moderate
  • RV systolic pressure (SP) >80 mmHg
  • Right-to-left (RL) shunting via an atrial septal defect (ASD) or ventricular septal defect (VSD)