Pulmonic regurgitation overview: Difference between revisions

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Pulmonary valve regurgitation is a condition where the [[pulmonary valve]] is not strong enough to prevent backflow into the [[right ventricle]].  Nearly all individuals have physiologic (trace-to-mild) pulmonic regurgitation, and the incidence increases with advancing age.  Hence, there is a backward flow of blood from the [[pulmonary artery]], through the [[pulmonary valve]], and into the [[right ventricle]] of the heart during [[diastole]].  
Pulmonary valve regurgitation is a condition where the [[pulmonary valve]] is not strong enough to prevent backflow into the [[right ventricle]].  Nearly all individuals have physiologic (trace-to-mild) pulmonic regurgitation, and the incidence increases with advancing age.  Hence, there is a backward flow of blood from the [[pulmonary artery]], through the [[pulmonary valve]], and into the [[right ventricle]] of the heart during [[diastole]].  


Pulmonary valve regurgitation may be classified according to pulmonary valve morphology and severity of the disease. The most common causes of pulmonary regurgitation includes repair of tetralogy of fallot and pulmonary stenosis. However, in small percentage of patients, it is a normal finding. Pulmonary valve regurgitation may share overlapping symptoms with certain other conditions such as [[aortic regurgitation]], [[Tricuspid regurgitation|tricuspid re gurgitation]], left to right shunting, right ventricular cardiomyopathy, [[pulmonary hypertension]], [[infective endocarditis]], carcinoid heart disease, [[syphilis]] and [[Marfan's syndrome|marfan syndrome]].  
Pulmonary valve regurgitation may be classified according to pulmonary valve morphology and severity of the disease.<ref name="pmid23922549">{{cite journal| author=Di Lullo L, Floccari F, Rivera R, Barbera V, Granata A, Otranto G et al.| title=Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists. | journal=Cardiorenal Med | year= 2013 | volume= 3 | issue= 2 | pages= 96-103 | pmid=23922549 | doi=10.1159/000350952 | pmc=3721135 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23922549  }} </ref> The most common causes of pulmonary regurgitation includes repair of tetralogy of fallot and pulmonary stenosis.<ref name="pmid11436049">{{cite journal| author=Bacha EA, Scheule AM, Zurakowski D, Erickson LC, Hung J, Lang P et al.| title=Long-term results after early primary repair of tetralogy of Fallot. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 1 | pages= 154-61 | pmid=11436049 | doi=10.1067/mtc.2001.115156 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11436049  }}</ref> However, in small percentage of patients, it is a normal finding. Pulmonary valve regurgitation may share overlapping symptoms with certain other conditions such as [[aortic regurgitation]], [[Tricuspid regurgitation|tricuspid re gurgitation]], left to right shunting, right ventricular cardiomyopathy, [[pulmonary hypertension]], [[infective endocarditis]], carcinoid heart disease, [[syphilis]] and [[Marfan's syndrome|marfan syndrome]].<ref name="pmid27828830">{{cite journal| author=Graziosi M, Rapezzi C| title=Right ventricular arrhythmogenic cardiomyopathy: genetic and MR for modern clinical diagnosis. | journal=J Cardiovasc Med (Hagerstown) | year= 2016 | volume=  | issue=  | pages=  | pmid=27828830 | doi=10.2459/JCM.0000000000000470 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27828830  }} </ref>


The main pathophysiologic mechanism for pulmonary regurgitation includes backflow of blood into right ventricle resulting in ventricular overload and ventricular remodelling. Complications which may result from pulmonary regurgitation include progressive right ventricular dilatation, [[heart failure]], [[tricuspid regurgitation]], ventricular arrythmias, and sudden cardiac death.   
The main pathophysiologic mechanism for pulmonary regurgitation includes backflow of blood into right ventricle resulting in ventricular overload and ventricular remodelling. Complications which may result from pulmonary regurgitation include progressive right ventricular dilatation, [[heart failure]], [[tricuspid regurgitation]], ventricular arrythmias, and sudden cardiac death.<ref name="pmid26430501">{{cite journal| author=Bigdelian H, Mardani D, Sedighi M| title=The Effect of Pulmonary Valve Replacement (PVR) Surgery on Hemodynamics of Patients Who Underwent Repair of Tetralogy of Fallot (TOF). | journal=J Cardiovasc Thorac Res | year= 2015 | volume= 7 | issue= 3 | pages= 122-5 | pmid=26430501 | doi=10.15171/jcvtr.2015.26 | pmc=4586599 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26430501  }} </ref>  


The diagnosis of pulmonic regugitation may include detailed history, and physical examination. Certain diagnostic tests such as [[echocardiography]] and [[cardiac MRI]] may help confirm the diagnosis. The mainstay of treatment for pulmonary regurgitation may include medical therapy for mild to moderate cases and pulmonary valve replacement in severe cases. Medical therapy may include use of [[Diuretic|diuretics]] and [[ACE inhibitor|ACE inhibitors]] in patients wit right ventricular dysfunction.   
The diagnosis of pulmonic regugitation may include detailed history, and physical examination.<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e143-263 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }} </ref> Certain diagnostic tests such as [[echocardiography]] and [[cardiac MRI]] may help confirm the diagnosis.<ref name="pmid20620859">{{cite journal| author=Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al.| title=Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. | journal=J Am Soc Echocardiogr | year= 2010 | volume= 23 | issue= 7 | pages= 685-713; quiz 786-8 | pmid=20620859 | doi=10.1016/j.echo.2010.05.010 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20620859  }} </ref><ref name="pmid24468055">{{cite journal| author=Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM et al.| title=Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology. | journal=J Am Soc Echocardiogr | year= 2014 | volume= 27 | issue= 2 | pages= 111-41 | pmid=24468055 | doi=10.1016/j.echo.2013.11.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24468055  }} </ref> The mainstay of treatment for pulmonary regurgitation may include medical therapy for mild to moderate cases and pulmonary valve replacement in severe cases. Medical therapy may include use of [[Diuretic|diuretics]] and [[ACE inhibitor|ACE inhibitors]] in patients wit right ventricular dysfunction.<ref name="pmid12354712">{{cite journal| author=Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ et al.| title=Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot. | journal=Circulation | year= 2002 | volume= 106 | issue= 12 Suppl 1 | pages= I69-75 | pmid=12354712 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12354712  }} </ref><ref name="pmid16638542">{{cite journal| author=Geva T| title=Indications and timing of pulmonary valve replacement after tetralogy of Fallot repair. | journal=Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu | year= 2006 | volume=  | issue=  | pages= 11-22 | pmid=16638542 | doi=10.1053/j.pcsu.2006.02.009 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16638542  }}</ref> 
 
Lifelong follow up may be required in patients with pulmonic regurgitation to monitor pulmonary valve morphology and to assess right ventricular function.<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e143-263 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677 }} </ref>


Lifelong follow up may be required in patients with pulmonic regurgitation to monitor pulmonary valve morphology and to assess right ventricular function. 
==Historical perspective ==
==Historical perspective ==
The pulmonary valve and its function of allowing blood to the lungs for nourishment was first described by Hippocrates. Erasistratus, mentioned the involvement of the pulmonary valve in the unidirectional flow. Realdo Colombo described the pulmonary circulation for the first time.<ref name="ParaskevasKoutsouflianiotis2017">{{cite journal|last1=Paraskevas|first1=G.|last2=Koutsouflianiotis|first2=K.|last3=Iliou|first3=K.|title=The first descriptions of various anatomical structures and embryological remnants of the heart: A systematic overview|journal=International Journal of Cardiology|volume=227|year=2017|pages=674–690|issn=01675273|doi=10.1016/j.ijcard.2016.10.077}}</ref>
The pulmonary valve and its function of allowing blood to the lungs for nourishment was first described by Hippocrates. Erasistratus, mentioned the involvement of the pulmonary valve in the unidirectional flow. Realdo Colombo described the pulmonary circulation for the first time.<ref name="ParaskevasKoutsouflianiotis2017">{{cite journal|last1=Paraskevas|first1=G.|last2=Koutsouflianiotis|first2=K.|last3=Iliou|first3=K.|title=The first descriptions of various anatomical structures and embryological remnants of the heart: A systematic overview|journal=International Journal of Cardiology|volume=227|year=2017|pages=674–690|issn=01675273|doi=10.1016/j.ijcard.2016.10.077}}</ref>

Revision as of 18:15, 6 January 2017

Pulmonic regurgitation Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differential diagnosis

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Electrocardiogram

Chest X-Ray

Echocardiography

Cardiac MRI

Severity Assessment

Treatment

Medical Therapy

Surgical therapy

Follow up

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2], Aravind Kuchkuntla, M.B.B.S[3]

Overview

Pulmonary valve regurgitation is a condition where the pulmonary valve is not strong enough to prevent backflow into the right ventricle. Nearly all individuals have physiologic (trace-to-mild) pulmonic regurgitation, and the incidence increases with advancing age. Hence, there is a backward flow of blood from the pulmonary artery, through the pulmonary valve, and into the right ventricle of the heart during diastole.

Pulmonary valve regurgitation may be classified according to pulmonary valve morphology and severity of the disease.[1] The most common causes of pulmonary regurgitation includes repair of tetralogy of fallot and pulmonary stenosis.[2] However, in small percentage of patients, it is a normal finding. Pulmonary valve regurgitation may share overlapping symptoms with certain other conditions such as aortic regurgitation, tricuspid re gurgitation, left to right shunting, right ventricular cardiomyopathy, pulmonary hypertension, infective endocarditis, carcinoid heart disease, syphilis and marfan syndrome.[3]

The main pathophysiologic mechanism for pulmonary regurgitation includes backflow of blood into right ventricle resulting in ventricular overload and ventricular remodelling. Complications which may result from pulmonary regurgitation include progressive right ventricular dilatation, heart failure, tricuspid regurgitation, ventricular arrythmias, and sudden cardiac death.[4]

The diagnosis of pulmonic regugitation may include detailed history, and physical examination.[5] Certain diagnostic tests such as echocardiography and cardiac MRI may help confirm the diagnosis.[6][7] The mainstay of treatment for pulmonary regurgitation may include medical therapy for mild to moderate cases and pulmonary valve replacement in severe cases. Medical therapy may include use of diuretics and ACE inhibitors in patients wit right ventricular dysfunction.[8][9]

Lifelong follow up may be required in patients with pulmonic regurgitation to monitor pulmonary valve morphology and to assess right ventricular function.[5]

Historical perspective

The pulmonary valve and its function of allowing blood to the lungs for nourishment was first described by Hippocrates. Erasistratus, mentioned the involvement of the pulmonary valve in the unidirectional flow. Realdo Colombo described the pulmonary circulation for the first time.[10]

Classification

Pulmonary valve regurgitation may be classified according to pulmonary valve morphology and severity of the disease. According to the pulmonary valve morphology, it may be classified into primary and secondary or functional regurgitation. Severity of disease may classify into mild, moderate and severe disease.[11][1][6]

Pathophysiology

Pathophysiologic mechanism of pulmonic regurgitation include right ventricular overload resulting in right ventricular remodelling and progressive decline in function. The rate of decline in right ventricular systolic function is affected by associated conditions such as peripheral pulmonary artery stenosis and pulmonary hypertension which further increase the severity of pulmonary regurgitation.[4]

Causes

A small percentage of pulmonic regurgitation is normal and occasionally can be heard in thin subjects. The most common causes of pulmonary regurgitation are following repair of tetralogy of fallot and pulmonary stenosis.[2][12][13][14]

Differential Diagnosis

The diseases which may present with overlapping symptoms as pulmonic regurgitation may include aortic regurgitation, tricuspid regurgitation, left to right shunting, right ventricular cardiomyopathy, pulmonary hypertension, infective endocarditis, carcinoid heart disease, syphilis and marfan syndrome.[15][16][3]

Epidemiology and demograpics

The prevalence of mild pulmonary regurgutation is present in 40% to 78% of patients with normal pulmonary valve anatomy.[17][18] There is increased prevalence of pulmonary regurgitation with increasing age.

Risk factors

The risk factors of pulmonic regurgitation may include pulmonary hypertension, surgical repair of tetralogy of fallot, endocarditis, left sided heart disease, previous ross procedure, collagen vascular disease, and involving the main pulmonary artery.[19][20][11][21]

Screening

There are no specific screening recommendations for patients with pulmonary regurgitation.[22]

Natural history, complications and prognosis

Majority of patients with mild PR are asymptomatic and have a benign course, not progressing to chronic PR. Patients tolerate severe chronic PR for a long period of time and begin to develop symptoms when the right ventricle function begins to decline. Chronic severe PR leads to progressive dilation and systolic dysfunction of the right ventricle resulting in symptoms.[5] Complications which may result from pulmonary regurgitation include progressive right ventricular dilatation, heart failure, tricuspid regurgitation, ventricular arrythmias, and sudden cardiac death. Symptomatic patients are treated with pulmonary valve replacement and have a good prognosis.[23]

Diagnosis

The diagnosis of pulmonic regurgitation may include detailed history, physical examination and diagnostic tests such as EKG, echocardiography, chest x ray and cardiac MRI.

History and symptoms

Clinical presentation of pulmonary regurgitation varies on the severity of the regurgitation and right ventricular dysfunction. Isolated pulmonary regurgitation is usually asymptomatic. However, patients with chronic PR may present with ankle edema, swelling of feet or legs, dyspnea on exertion, fatigue, hemoptysis, nocturnal cough and palpitations.[5][24]

Physical examination

Physical examination findings of pulmonary regurgitation includes increased JVP, prominent "a" wave, "v" wave in the neck. A palpable impulse (lift or heave) is usually present at the left lower sternal border because of right ventricular dilation. On auscultation, it may be associated with wide splitting of S2 with right sided S3 accentuated with respiration. Murmer of pulmonic regurgitation may vary depending on the underlying cause.[25][26]

Electrocardiogram

EKG findings in patients wit chronic PR may be non specific. However, in patients with tetrology of fallot may show increased QRS duration with widened QRS complex. It may reflect the severity of PR and right ventricular dilation predisposing the patient to develop arrythmias. [27][28]

Chest x ray

Chest x ray may not be required for the diagnosis of pulmonic regurgitation. However, lateral and PA view of chest radiograph may help determining the right ventricular enlargement. Right atrial enlargement may also be seen in patients with concomitant tricuspid regurgitation.[29]

Echocardiography

Echocardiography is the initial test which may be used to assess pulmonary valve morphology, RVOT anatomy, and to identify the presence and quantify the severity of PR. Different modes of echocardiography may be used to improve the accuracy of findings and assess the severity of the disease which include colour flow doppler, flow convergence method, pulsed doppler, spectral doppler and exercise echocardiography.[7][6][30]

Cardiac MRI

Cardiac magnetic resonance(CMR) is a gold standard for assessment of morphology of the pulmonary valve, for quantification of the severity of the regurgitation and the RV systolic function. CMR is useful in quantification of the regurgitant volume and regurgitant fraction of PR by using sequences called “velocity- encoded phase-contrast images”.[31] CMR is useful for evaluating pulmonary regurgitant fraction, RV end-diastolic and end- systolic volumes, and RV ejection fraction. CMR is the diagnostic modality preffered to determine the requirement of reintervention in patients with repaired tetralogy of Fallot and to assess the ventricular function and dimensions.

Pulmonary angiography

Pulmonary angiography may play a role in patients with tetrology of fallot repair having pulmonary regurgitation.[32]

Treatment

Treatment of pulmonic regurgitation may include medical therapy, surgical therapy and regular follow up.

Medical therapy

Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and beta blockers may be used to reverse neurohormonal activation and improve symptoms.[33][8] Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and patients previously having sustained bacterial endocarditis. Surgical management of pulmonic regurgitation may include replacement of pulmonary valve.

Surgical therapy

Surgical management of pulmonic regurgitation may include replacement of pulmonary valve. The major indications for pulmonic valve replacement may include symptomatic patients with arrythmias or NYHA class higher than II, ejection fraction of less than 40% when assessed with CMR, patients with progressive right ventricular regurgitation(right ventricular end- diastolic volume ≥160 mL/m2 or end-systolic volume ≥82 mL/m2 on CMR), moderate to severe tricuspid valve regurgitation, resulting from annular dilation, patients at risk of developing arrythmias and with prolonged QRS duration.(total QRS duration ≥180 msec, or QRS duration increase >3.5 msec per year and severe pulmonic regurgitation in a patient with another cardiac lesion that requires operative intervention.[9]

Follow up

Follow up of patients with pulmonic regurgitation requires regular echocardiographic monitoring after PVR, oral anticoagulation in patients with mechanical or bioprosthetic valves and lifelong follow up to monitor pulmonary valve morphology and RV function.[5]

References

  1. ↑ 1.0 1.1 Di Lullo L, Floccari F, Rivera R, Barbera V, Granata A, Otranto G; et al. (2013). "Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists". Cardiorenal Med. 3 (2): 96–103. doi:10.1159/000350952. PMC 3721135. PMID 23922549.
  2. ↑ 2.0 2.1 Bacha EA, Scheule AM, Zurakowski D, Erickson LC, Hung J, Lang P; et al. (2001). "Long-term results after early primary repair of tetralogy of Fallot". J Thorac Cardiovasc Surg. 122 (1): 154–61. doi:10.1067/mtc.2001.115156. PMID 11436049.
  3. ↑ 3.0 3.1 Graziosi M, Rapezzi C (2016). "Right ventricular arrhythmogenic cardiomyopathy: genetic and MR for modern clinical diagnosis". J Cardiovasc Med (Hagerstown). doi:10.2459/JCM.0000000000000470. PMID 27828830.
  4. ↑ 4.0 4.1 Bigdelian H, Mardani D, Sedighi M (2015). "The Effect of Pulmonary Valve Replacement (PVR) Surgery on Hemodynamics of Patients Who Underwent Repair of Tetralogy of Fallot (TOF)". J Cardiovasc Thorac Res. 7 (3): 122–5. doi:10.15171/jcvtr.2015.26. PMC 4586599. PMID 26430501.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e143–263. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
  6. ↑ 6.0 6.1 6.2 Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K; et al. (2010). "Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography". J Am Soc Echocardiogr. 23 (7): 685–713, quiz 786-8. doi:10.1016/j.echo.2010.05.010. PMID 20620859.
  7. ↑ 7.0 7.1 Valente AM, Cook S, Festa P, Ko HH, Krishnamurthy R, Taylor AM; et al. (2014). "Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology". J Am Soc Echocardiogr. 27 (2): 111–41. doi:10.1016/j.echo.2013.11.009. PMID 24468055.
  8. ↑ 8.0 8.1 Davos CH, Davlouros PA, Wensel R, Francis D, Davies LC, Kilner PJ; et al. (2002). "Global impairment of cardiac autonomic nervous activity late after repair of tetralogy of Fallot". Circulation. 106 (12 Suppl 1): I69–75. PMID 12354712.
  9. ↑ 9.0 9.1 Geva T (2006). "Indications and timing of pulmonary valve replacement after tetralogy of Fallot repair". Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu: 11–22. doi:10.1053/j.pcsu.2006.02.009. PMID 16638542.
  10. ↑ Paraskevas, G.; Koutsouflianiotis, K.; Iliou, K. (2017). "The first descriptions of various anatomical structures and embryological remnants of the heart: A systematic overview". International Journal of Cardiology. 227: 674–690. doi:10.1016/j.ijcard.2016.10.077. ISSN 0167-5273.
  11. ↑ 11.0 11.1 Chaturvedi RR, Redington AN (2007). "Pulmonary regurgitation in congenital heart disease". Heart. 93 (7): 880–9. doi:10.1136/hrt.2005.075234. PMC 1994453. PMID 17569817.
  12. ↑ Jonas SN, Kligerman SJ, Burke AP, Frazier AA, White CS (2016). "Pulmonary Valve Anatomy and Abnormalities: A Pictorial Essay of Radiography, Computed Tomography (CT), and Magnetic Resonance Imaging (MRI)". J Thorac Imaging. 31 (1): W4–12. doi:10.1097/RTI.0000000000000182. PMID 26656195.
  13. ↑ Ansari MM, Cardoso R, Garcia D, Sandhu S, Horlick E, Brinster D; et al. (2015). "Percutaneous Pulmonary Valve Implantation: Present Status and Evolving Future". J Am Coll Cardiol. 66 (20): 2246–55. doi:10.1016/j.jacc.2015.09.055. PMID 26564602.
  14. ↑ Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease)". Circulation. 118 (23): 2395–451. doi:10.1161/CIRCULATIONAHA.108.190811. PMID 18997168.
  15. ↑ Template:Citejournal
  16. ↑ Sepulveda, G.; Lukas, D. S. (1955). "The Diagnosis of Tricuspid Insufficiency: Clinical Features in 60 Cases with Associated Mitral Valve Disease". Circulation. 11 (4): 552–563. doi:10.1161/01.CIR.11.4.552. ISSN 0009-7322.
  17. ↑ Choong CY, Abascal VM, Weyman J, Levine RA, Gentile F, Thomas JD; et al. (1989). "Prevalence of valvular regurgitation by Doppler echocardiography in patients with structurally normal hearts by two-dimensional echocardiography". Am Heart J. 117 (3): 636–42. PMID 2784023.
  18. ↑ Takao S, Miyatake K, Izumi S, Okamoto M, Kinoshita N, Nakagawa H; et al. (1988). "Clinical implications of pulmonary regurgitation in healthy individuals: detection by cross sectional pulsed Doppler echocardiography". Br Heart J. 59 (5): 542–50. PMC 1276894. PMID 3382565.
  19. ↑ Harrild DM, Powell AJ, Tran TX, Trang TX, Geva T, Lock JE; et al. (2010). "Long-term pulmonary regurgitation following balloon valvuloplasty for pulmonary stenosis risk factors and relationship to exercise capacity and ventricular volume and function". J Am Coll Cardiol. 55 (10): 1041–7. doi:10.1016/j.jacc.2010.01.016. PMC 4235281. PMID 20202522.
  20. ↑ Ammash NM, Dearani JA, Burkhart HM, Connolly HM (2007). "Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement". Congenit Heart Dis. 2 (6): 386–403. doi:10.1111/j.1747-0803.2007.00131.x. PMID 18377431.
  21. ↑ Rebergen SA, Chin JG, Ottenkamp J, van der Wall EE, de Roos A (1993). "Pulmonary regurgitation in the late postoperative follow-up of tetralogy of Fallot. Volumetric quantitation by nuclear magnetic resonance velocity mapping". Circulation. 88 (5 Pt 1): 2257–66. PMID 8222120.
  22. ↑ Mercer-Rosa L, Yang W, Kutty S, Rychik J, Fogel M, Goldmuntz E (2012). "Quantifying pulmonary regurgitation and right ventricular function in surgically repaired tetralogy of Fallot: a comparative analysis of echocardiography and magnetic resonance imaging". Circ Cardiovasc Imaging. 5 (5): 637–43. doi:10.1161/CIRCIMAGING.112.972588. PMC 3476467. PMID 22869820.
  23. ↑ Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY; et al. (2012). "Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement". J Am Coll Cardiol. 60 (11): 1005–14. doi:10.1016/j.jacc.2012.03.077. PMID 22921969.
  24. ↑ Shimazaki Y, Blackstone EH, Kirklin JW (1984). "The natural history of isolated congenital pulmonary valve incompetence: surgical implications". Thorac Cardiovasc Surg. 32 (4): 257–9. doi:10.1055/s-2007-1023399. PMID 6207619.
  25. ↑ Bousvaros, GeorgeA.; Deuchar, DennisC. (1961). "THE MURMUR OF PULMONARY REGURGITATION WHICH IS NOT ASSOCIATED WITH PULMONARY HYPERTENSION". The Lancet. 278 (7209): 962–964. doi:10.1016/S0140-6736(61)90798-X. ISSN 0140-6736.
  26. ↑ Würtemberger G, Dinkel E, Joos A, Matthys H (1989). "[Pulmonary hypertension. Clinical picture and therapy]". Radiologe. 29 (6): 263–6. PMID 2662241.
  27. ↑ Gatzoulis MA, Till JA, Somerville J, Redington AN (1995). "Mechanoelectrical interaction in tetralogy of Fallot. QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death". Circulation. 92 (2): 231–7. PMID 7600655.
  28. ↑ Abd El Rahman MY, Abdul-Khaliq H, Vogel M, Alexi-Meskishvili V, Gutberlet M, Lange PE (2000). "Relation between right ventricular enlargement, QRS duration, and right ventricular function in patients with tetralogy of Fallot and pulmonary regurgitation after surgical repair". Heart. 84 (4): 416–20. PMC 1729453. PMID 10995413.
  29. ↑ https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017
  30. ↑ Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA; et al. (2003). "Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography". J Am Soc Echocardiogr. 16 (7): 777–802. doi:10.1016/S0894-7317(03)00335-3. PMID 12835667.
  31. ↑ Wald RM, Redington AN, Pereira A, Provost YL, Paul NS, Oechslin EN; et al. (2009). "Refining the assessment of pulmonary regurgitation in adults after tetralogy of Fallot repair: should we be measuring regurgitant fraction or regurgitant volume?". Eur Heart J. 30 (3): 356–61. doi:10.1093/eurheartj/ehn595. PMID 19164336.
  32. ↑ Erdoğan I, Celiker A, Hazirolan T, Haliloğlu M, Karagöz T (2010). "Angiocardiography and magnetic resonance imaging to assess pulmonary regurgitation in repaired tetralogy of Fallot". Anadolu Kardiyol Derg. 10 (4): 353–7. doi:10.5152/akd.2010.095. PMID 20693132.
  33. ↑ Bolger AP, Sharma R, Li W, Leenarts M, Kalra PR, Kemp M; et al. (2002). "Neurohormonal activation and the chronic heart failure syndrome in adults with congenital heart disease". Circulation. 106 (1): 92–9. PMID 12093776.

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