Pulmonary Insufficiency
Definition
The backward or retrograde flow of blood through the pulmonary valve into the right ventricle during diastole; may be acute or chronic.
Etiology
- Pulmonary hypertension (causing insufficiency secondary to dilatation of the valve ring)
- Infective endocarditis
- Rheumatic heart disease
- Congenital abnormalities (e. g., tetralogy of Fallot, ventricular septal defect, valvular pulmonic stenosis)
- Carcinoid heart disease
- Pulmonary valve repair
Signs and Symptoms
- May be tolerated for years without problems
- Dyspnea
Complications
- Right heart failure
Cardiac Auscultation
- Low-pitched murmur, usually best heard along the third or fourth intercostal spaces adjacent to the left sternal border; may be accentuated with inspiration
- When the pulmonary artery systolic pressure exceeds 70 mm Hg, dilatation of the pulmonary artery ring results in Graham-Steell's murmur, a high-pitched, blowing decrescendo murmur heard best along the left parasternal region
- Wide splitting of S2
- Right-sided S3 may be audible and Accentuated with inspiration
- Right-sided S4 may be audible and accentuated with inspiration
Electrocardiogram
- Right ventricular hypertrophy
- Right bundle branch block
Chest X-ray
- Enlarged pulmonary artery
- Enlarged right ventricle
Treatment
- Pulmonary insufficiency is usually well tolerated
- Valvuloplasty/valve replacement
M-Mode
- Right ventricular enlargement
- Right ventricular volume overload pattern (see TR)
- Fine diastolic flutter of the tricuspid valve
- Premature opening of the pulmonic valve (defined as pulmonic valve opening on or before the QRS complex) due to severe acute pulmonary insufficiency
2-D
- Anatomic basis for the presence of pulmonary insufficiency (e.g. infective endocarditis, valvular pulmonic stenosis)
- Dilatation of the right ventricle
- Right ventricular volume overload pattern
PW Doppler
- Up to 87% of normal patients appear to have pulmonary insufficiency Calculate the length and duration of the regurgitant jet to differentiate between true and physiologic insufficiency (< 1 cm in length and not holodiastolic in duration)
- Determine the severity of pulmonary insufficiency with mapping technique
CW Doppler
- Compare the regurgitant Doppler spectral display with the pulmonic outflow Doppler spectral display
- Determine the pulmonary artery end-diastolic pressure
Color Flow Doppler
- Determine the length and width of the pulmonary insufficiency
- Proximal acceleration (flow convergence) may indicate 3+ or 4+ pulmonary insufficiency
Pulmonary Insufficiency Severity Scales
PW and Color flow Doppler
- Physiologic : < 1 cm in length and not holodiastolic in duration
- Borderline : 1 to 2 cm in length and holodiastolic in duration
- Clinically significant : > 2 cm in length with a peak velocity > 1. 5 m/sec and holodiastolic in duration
CW Doppler Spectral Strength of Regurgitant Jet
- Grade 1+ : Spectral tracing stains sufficiently for detection, but not enough for clear delineation
- Grade 2+ : Complete spectral tracing can just be seen
- Grade 3+ : Distinct darkening of spectral tracing is visible but density is less than antegrade flow
- Grade 4+ : Dark-stained spectral tracing