Pulmonary stenosis clinical features and management

PULMONARY STENOSIS

PULMONARY STENOSIS

Pulmonary stenosis is the second most common form of congenital heart disease in adults; it is commoner in women. Mild cases, with gradients of less than 5OmmHg,are common. Stenosis may occur at valvular or subvalvular level, or even in the pulmonary arteries. There is araised pressure in the right ventricle and, in severe cases,reduced lung blood flow and poor effort tolerance.

Clinical features

Most cases are asymptomatic. With gradients of overSOmmHg, the most common symptom is dyspnoea onexertion. In very severe stenosis symptoms of exertionalsyncope and angina become prominent, similar to thoseassociated with aortic stenosis. In children and youngadults, pulmonary stenosis may present with severe rightheart failure.

The physical signs are of a small volume pulse, a large awave in the JVP, a right ventricular substernal heave anda harsh systolic murmur in the pulmonary area. The latterappears very long and drowns the heart sounds in severecases of infundibular stenosis, but can be a short ejectionmurmur in mild cases. The timing of pulmonary valveclosure, which is delayed in severe cases, is a useful indicationof severity.

Investigation and management

ECG shows right ventricular hypertrophy. The chest X-rayshows oligaemic lung fields; a large poststenotic dilatationwith dilatation of the pulmonary conus is common invalvular, but not infundibular, stenosis. The right ventricleis not significantly enlarged unless it has failed.Doppler ultrasound assesses the valve gradient. Echocardiographywill show the hypertrophy of the right ventricle and the site of the obstruction.Surgical valvotomy has been largely replaced as a treatmentfor pulmonary stenosis by balloon valvuloplasty.

Pulmonary stenosis clinical features and management

By: Dr Izharul Hasan

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