cardiovascular disorders
Pulmonic Stenosis
Symptoms and Signs of Pulmonic Stenosis
Many children with pulmonic stenosis remain asymptomatic for years and do not develop symptoms until adulthood. Even in adulthood, many patients remain asymptomatic. When symptoms of pulmonic stenosis develop, they resemble those of Aortic Stenosis (syncope, angina, dyspnea). Visible and palpable signs reflect the effects of right ventricular (RV) hypertrophy and include a prominent jugular venousawave (due to forceful atrial contraction against a hypertrophied RV), an RV precordial lift or heave, and a left parasternal systolic thrill at the second intercostal space. Widened second heart sound (S2) and delayed pulmonic component of S2 (P2) Harsh crescendo-decrescendo ejection murmur On auscultation, the first heart sound (S1) is normal and the normal splitting of the S2 is widened because of prolonged pulmonic ejection (P2 is delayed). In RV failure and hypertrophy, the third and fourth heart sounds (S3 and S4) are rarely audible at the left parasternal fourth intercostal space. A click in congenital PS is thought to result from abnormal ventricular wall tension. The click occurs early in systole (very near S1) and is not affected by hemodynamic changes. A harsh crescendo-decrescendo ejection murmur is audible and is heard best at the left parasternal second (valvular stenosis) or fourth (infundibular stenosis) intercostal space with the diaphragm of the stethoscope when the patient leans forward. Unlike the aortic stenosis murmur, a pulmonic stenosis murmur does not radiate, and the crescendo component lengthens as stenosis progresses. The murmur grows louder immediately with Valsalva release and with inspiration; the patient may need to be standing for this effect to be heard. 