Pulmonary Regurgitation

• Pathophys/progression of PR


  PR → increased RV pressure → volume overload & dilation of RV with compensatory RV hypertrophy → eventually, leads to equalisation of pulmonary artery & RV pressure in diastole → RHF
• What are the signs & symptoms of PR?


  SOB

  Fatigue

  Decreased exercise tolerance

  Orthopnoea

  PND

  Palpitations

  Diaphoresis

  Diastolic murmur (low-pitched decrescendo murmur, along L sternal border)

  Systolic murmur (low-pitched along L sternal border)

  Displaced point of max apical impulse

  Signs of RHF
• What are the RFs of PR?


  Pulmonary HTN

  Surgical repair of tetralogy of Fallot, pulmonary stenosis or pulmonary atresia

  Endocarditis

  LHF

  Previous Ross procedure

  Collagen vascular disease

  Malignancies involving main pulmonary artery (rare)
• What are the Inx for PR?


  Obs

  Full Hx & examination

  ECG

  Bloods (FBC, U&Es, LFTs, CRP)

  CXR

  Echo

  CT/MRI
• What might an ECG show in PR?


  Non-specific

  May have RBBB or right axis deviation
• What might a CXR show in PR?


  Pulmonary artery dilation with clear lung fields

  RV dilation
• Why is Echo used in PR?


  Useful for determining severity, mechanism, aetiology, right ventricular (RV) size and function, other valvular abnormalities, and RV systolic pressure
• What does CT/MRI show in PR?


  Measurement of pulmonary regurgitant fraction, right ventricular (RV) end-diastolic and end-systolic volumes, and RV ejection fraction
• What are the DDx of PR?


  Mitral stenosis

  Aortic regurgitation

  Atrial myxoma
• How can mitral stenosis be differentiated from PR?


  • Presentation → Malar flush, low volume pulse, a tapping and undisplaced apex beat, and loud S1 with an opening snap
  • Murmur → rumbling & mid-diastolic
  • CXR → pulmonary oedema, enlarged left atrium, and mitral valve calcification
  • ECG → can present with AF & RV hypertrophy
  • Echo → diagnostic
• How can aortic regurgitation be differentiated from PR?


  • Murmur → early diastolic, increased in duration to holodiastolic in severe AR
  • CXR → May show cardiomegaly
  • ECG → may show non-specific ST-T wave changes, left axis deviation, or conduction abnormalities
  • Echo → detection of cause of aortic valve pathology
• How can atrial myxoma be differentiated from PR?


  • Murmur → mid-late diastolic, and changes in character and intensity with alterations in position
  • Echo → Mass present (usually attached to the interatrial septum or free wall of the atrium)
• What is the treatment of acute PR?


  Non-severe

  • medical management of HF

  Severe

  • medical management of HF
  • consider inotropic support + pulmonary valve replacement
• What is the treatment of chronic PR?


  • Asymptomatic
  • Treatment of underlying cause
  • Consider pulmonary valve replacement ± anticoagulation
  • Symptomatic
  • NYHA Class I
  • Treatment of underlying cause + medical management of HF (1st line)
  • Consider pulmonary valve replacement ± anticoagulation
  • NYHA Class II or III
  • Treatment of underlying cause + medical management of HF
  • PLUS pulmonary valve replacement ± anticoagulation
  • NYHA Class IV
  • Treatment of underlying cause + individualised medical and/or surgical treatment