Pulmonary valve disease
Pulmonary regurgitation and stenosis — the forgotten valve after tetralogy repair, in pulmonary hypertension and in carcinoid.
Numbers to remember
- Pulmonary stenosis is severe when the peak velocity is >4 m/s (peak gradient >64 mmHg) [6,194]
- Severe pulmonary regurgitation: a wide jet filling the RVOT and a dense CW signal that ends early in diastole [4,194]
- After tetralogy repair, decisions follow RV volumes and symptoms, not the PR jet alone [25]
Questions echo must answer
- Is there stenosis or regurgitation, and how severe?[4,194]
- MechanismCongenital, post-tetralogy repair, carcinoid, endocarditis, pulmonary hypertension (functional PR) [25,194].
- ConsequencesRV size and function [3].
- PressureThe early-diastolic PR velocity estimates mean pulmonary artery pressure [8].
Acquisition protocol
- PSAX at the aortic valve level and the RV outflow viewLeaflets, annulus, colour.
- SubcostalOften better aligned in adults.
- CW through the valvePeak velocity; PR envelope shape and pressure half-time.
- RVSize and function in the RV-focused view [3].
Diagnosis & severity
| Lesion | Severe |
|---|---|
| Pulmonary stenosis | Peak velocity >4 m/s, peak gradient >64 mmHg |
| Pulmonary regurgitation | Jet width >50–65% of the annulus, dense CW with steep deceleration, diastolic flow reversal in the branch pulmonary arteries |
Grading per the BSE and ASE guidance [4,194].
Thresholds that change management
- Severe pulmonary stenosis → balloon valvuloplasty for a domed, non-dysplastic valve [6,25].
- Severe PR after tetralogy repair → valve replacement for symptoms or progressive RV dilatation and dysfunction (CMR volumes) [25].
Pitfalls & mimics
- Trivial PR is normal A small central jet is seen in most people.
- Severe PR can look small on colour Laminar, low-velocity free regurgitation fills the RVOT quietly — look at the CW envelope [194].
- Left main coronary flow close to the pulmonary valve can mimic a PR jet.