cardiovascular disorders
Pulmonic Regurgitation
Symptoms and Signs of Pulmonic Regurgitation
Pulmonic regurgitation is usually asymptomatic. A few patients develop symptoms and signs of Classification . Palpable signs are attributable to Pulmonary Hypertension and RV hypertrophy. They include a palpable pulmonic component (P2) of the second heart sound (S2) at the left upper sternal border and a sustained RV impulse that is increased in amplitude at the left middle and lower sternal border. High-pitched, early diastolic decrescendo murmur On auscultation, the first heart sound (S1) is normal. The S2 may be split or single. When split, P2 may be loud and audible shortly after the aortic component of S2 (A2) because of pulmonary hypertension, or P2 may be delayed because of increased RV stroke volume. S2 may be single because of prompt pulmonic valve closing with a merged A2-P2 or, rarely, because of congenital absence of the pulmonic valve. An RV third heart sound (S3), fourth heart sound (S4), or both may be audible with RV dysfunction–induced HF or RV hypertrophy; these sounds can be distinguished from left ventricular heart sounds because they are located at the left parasternal fourth intercostal space and because they grow louder with inspiration. The murmur of PR due to pulmonary hypertension is a high-pitched, early diastolic decrescendo murmur that begins with P2 and ends before S1 and that radiates toward the mid-right sternal edge (Graham Steell murmur); it is heard best at the left upper sternal border with the diaphragm of the stethoscope while the patient holds the breath at end-expiration and sits upright. The murmur of PR without pulmonary hypertension is shorter, lower-pitched (rougher in quality), and begins after P2. Both murmurs may resemble the murmur of aortic regurgitation but can be distinguished by inspiration (which makes the PR murmur louder) and by Valsalva release. After Valsalva release, the PR murmur immediately becomes loud (because of immediate venous return to the right side of the heart), but the aortic regurgitation murmur requires 4 or 5 beats to do so. Also, a soft PR murmur may sometimes become even softer during inspiration because this murmur is usually best heard at the second left intercostal space, where inspiration pushes the stethoscope away from the heart. In some forms of congenital heart disease, the murmur of severe PR is quite short because the pressure gradient between the pulmonary artery and the right ventricle equalizes rapidly in diastole. 