The pulmonary valve
Minimum echocardiographic dataset
The minimum echocardiographic dataset for the pulmonary valve consists of:24
- appearance of the valve
- colour map – in severe regurgitation reversed flow fills the whole pulmonary artery lumen to the branches and beyond and the jet within the RV is broad
- spectral Doppler for systolic V max and regurgitant pressure half (typically <100 ms in severe pulmonary regurgitation [PR])
- effect on right ventricle
- pulmonary artery size
- pulmonary artery pressure which may drive the regurgitation.
Grading pulmonary valve disease
This is summarised in table 8.
Cardiac computed tomography in pulmonary disease
Since pulmonary stenosis is usually congenital in origin, cardiac CT may be useful in defining complex congenital heart anatomy. In patients with pulmonary stenosis, the leaflets are often thin and difficult to visualise directly and so surrogate markers of pulmonary stenosis are usually required. These include dilatation of the main pulmonary artery and left pulmonary artery, right ventricular hypertrophy, right atrial enlargement and bowing of the interatrial septum to the left in keeping with elevated right atrial pressures.
Cardiac CT is of limited use in evaluating PR and is confined to the detection of secondary effects such as dilatation of the pulmonary valve annulus, pulmonary artery dilatation and right ventricular dilatation.
Cardiac magnetic resonance imaging
Turbulent flow in pulmonary stenosis can be visualised with SSFP cine imaging. Although planimetry of the pulmonary valve is of limited use, as with the aortic valve, CMR is able to provide accurate peak velocity data across the aortic valve.
CMR is the gold standard for the assessment of PR.46 With visualisation of PR using cine SSFP imaging and the ability to accurately measure regurgitant volumes and regurgitant fractions with flow imaging, it has now become the technique of choice for the serial evaluation of patients with congenital heart disease, where progressive RV dilatation and RV dysfunction are important for the timing of pulmonary valve intervention.
Key learning messages
- Echocardiography is the mainstay of investigation
- CT and CMR are useful for the assessment of the aorta e.g. bicuspid aortic valve disease
- CT is useful in the work-up towards TAVI
- An ideal evaluation of a valvular lesion should include a description as to the aetiology of the valvular lesion, a qualitative and quantitative assessment of severity, an assessment of the haemodynamic effects on chamber size and function, and also an evaluation of concomitant valvular disease.
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