pulmonic valvular stenosis

^[1]^[2]

Etiology

often asymptomatic
prominent a-wave in jugular venous pulse
right ventricular heave
pulmonic ejection click immediately after S1
- diminishes with inspiration
- earlier the click, the more severe the stenosis
- click indicates valve is pliable & noncalcified
- results from rapid opening of the pulmonary vavle leaflets
systolic ejection murmur
- crescendo-decrescendo systolic murmur heard best at the upper left sternal border (2nd left intercostal space)^[2]
- radiation to the left clavicle
- the longer the murmur & later peaking, the more severe the stenosis
soft & late P2
- with more severe stenosis, P2 becomes inaudible
- S2 may become fixed with severe stenosis & inaudible P2^[2]
systolic thrill due to high flow velocity across the pulmonary valve^[2]

no treatment (surgery) unless
- symptomatic
- right ventricular pressure approaches 2/3 systemic pressure
- small pulmonary valve annulus
- pulmonary regurgitation > moderate
- subvalvular or supravalvular pulmonary stenosis
- cardiac surgery for another reason^[2]
repair of severe pulmonary valvular stenosis regardless of symptoms in a patient with Noonan's syndrome^[2]
- patients with dysplastic valve (Noonan's syndrome) should undergo pulmonary valve replacement
- participation in sports not recommended in patients with severe pulmonary valvular stenosis
  - pulmonary valve replacement recommended^[2]
percutaneous balloon valvuloplasty for pliable valve
- not clear that this would correct pulmonary regurgitation
surgical replacement for caclified valve
lifelong cardiac survelliance if:
- balloon valvuloplasty
- pulmonary valve replacement
prophylaxis for bacterial endocarditis not indicated

↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 47
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 ^2.6 ^2.7 ^2.8 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19 American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022.