Pulmonic regurgitation history and symptoms
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Pulmonic regurgitation Microchapters |
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Diagnosis |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]Aysha Anwar, M.B.B.S[3]
Overview
Clinical presentation of pulmonary regurgitation varies with the severity of the regurgitation and right ventricular dysfunction. Isolated pulmonary regurgitation is usually asymptomatic. However, patients with chronic PR may present with symptoms of heart failure such as ankle edema, swelling of feet or legs, dyspnea on exertion, fatigue, hemoptysis, nocturnal cough and palpitations.[1][2]
History
Patient history
- The patient history is highly dependant upon the etiology/ cause of PR. The patient may present with a history related to the primary cause of PR with no or trivial symptoms of PR except among the cases of severe PR progressing to right heart failure.
- Decreased exercise tolerance or dyspnea on exertion may be the first and most common complaint the patient notices and presents with.
- The symptoms of right heart failure due to PR may also include fatigue and abdominal fullness/bloating, and lower extremity swelling.[3]
- Mild PR[1]:
- Acute worsening of PR/ Acute PR: Usually a trauma may cause acute severe PR. History of congestive heart failure history and symptoms may be present in other cases.
- Isolated PR[3]:
- Post TOF repair:
- Post surgical or percutaneous repair of pulmonary stenosis or TOF, the patient gives a history related to severe regurgitation sequele.
- Pulmonary hypertension (PAH)[3]:
- Among patients with PR secondary to PAH, the history may incline to the primary lung disease or the high pulmonary vascular resistance rather heart failure symptoms such as volume overload.
- To read more about the history and symptoms of patients with PAH, click here.
- Infective endocarditis (IE):
- Patients with PR due to IE who develop septic pulmonary emboli and PAH may have a history of severe right heart failure.
Past medical history
Past medical history is important to assess the primary cause of PR or its associated cmplications.
Family history
A family history of TOF or autosomal dominant causes of PR such as Marfan syndrome may be helpful in determining the cause of the disease.
Social history
- Smoking: PAH a common cause of PR. Tobacco smoking is a risk factor for developing PAH.[4] Although, no direct correlation between smoking and PR has been reported, a history of smoking or associated COPD may be required for pre-operative clearancein case a corrective surgery is planned.
- Intravenous drug use (recreational): Infective endocarditis although an uncommon cause of PR is overwhelmingly a disease of IV drug abuse. In an urban university hospital NJ, USA, s prospective study reported that 13% of IV injection users with fever have echocardiographic evidence of IE.[5] Although pulmonary valve involvement is rare, but cases of PR among IV drug users have been reported.[6][7]
Allergies
A history of allergy to certain medications (such as penicillin, heparin, and anesthetic medications) and materials (such as latex or other prosthetic valve materials) is important for pre-operative clearance and planning on the choice of material for prosthetic valve.
Common symptoms
Clinical presentation of pulmonary regurgitation varies with the severity of the regurgitation and the right ventricular function.[1][2][8][9]:
- Isolated pulmonary regurgitation is usually asymptomatic and is an incidental finding on 2D echo even when the regurgitation is severe.
- Patients with chronic PR develop right heart failure and eventually left heart failure and present with the following symptoms:
- Initial symptoms of chronic PR is a functional limitation of physical activity
- Ankle edema or swelling of the feet and legs
- Dyspnea on exertion/ exercise intolerance (one of the early signs of heart failure). The manifestation is due to pulmonary edema in a patient with suboptimal cardiac pumping function.
- Fatigue
- Hemoptysis or frothy sputum
- Nocturnal cough
- At an early stage of RV dysfunction, the patients often fall in NYHA class 1 although symptoms may vary for a few patients.[9]
- Patients with arrythmias present with palpitations, dizziness, or an episode of syncope.[10][11]
- Symptoms of the underlying disease process may also be present.
Associated symptoms
PR is a secondary disease and it is important to assess the causative lesion. Symptoms of the primary disease or disorder may include:
- To read about the symptoms and history of TOF, the repair of which is a common cause of PR, click here.
References
- ↑ 1.0 1.1 1.2 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.
- ↑ 2.0 2.1 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.
- ↑ 3.0 3.1 3.2 Chaturvedi RR, Redington AN (July 2007). "Pulmonary regurgitation in congenital heart disease". Heart. 93 (7): 880–9. doi:10.1136/hrt.2005.075234. PMC 1994453. PMID 17569817.
- ↑ Schiess R, Senn O, Fischler M, Huber LC, Vatandaslar S, Speich R, Ulrich S (November 2010). "Tobacco smoke: a risk factor for pulmonary arterial hypertension? A case-control study". Chest. 138 (5): 1086–92. doi:10.1378/chest.09-2962. PMID 20472864.
- ↑ Weisse AB, Heller DR, Schimenti RJ, Montgomery RL, Kapila R (March 1993). "The febrile parenteral drug user: a prospective study in 121 patients". Am. J. Med. 94 (3): 274–80. doi:10.1016/0002-9343(93)90059-x. PMID 8452151.
- ↑ Hecht SR, Berger M (October 1992). "Right-sided endocarditis in intravenous drug users. Prognostic features in 102 episodes". Ann. Intern. Med. 117 (7): 560–6. doi:10.7326/0003-4819-117-7-560. PMID 1524330.
- ↑ Moss R, Munt B (May 2003). "Injection drug use and right sided endocarditis". Heart. 89 (5): 577–81. doi:10.1136/heart.89.5.577. PMC 1767660. PMID 12695478.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ 9.0 9.1 Bouzas, Beatriz; Kilner, Philip J.; Gatzoulis, Michael A. (2005). "Pulmonary regurgitation: not a benign lesion". European Heart Journal. 26 (5): 433–439. doi:10.1093/eurheartj/ehi091. ISSN 0195-668X.
- ↑ Bouzas B, Kilner PJ, Gatzoulis MA (2005). "Pulmonary regurgitation: not a benign lesion". Eur Heart J. 26 (5): 433–9. doi:10.1093/eurheartj/ehi091. PMID 15640261.
- ↑ Wessel HU, Cunningham WJ, Paul MH, Bastanier CK, Muster AJ, Idriss FS (1980). "Exercise performance in tetralogy of Fallot after intracardiac repair". J Thorac Cardiovasc Surg. 80 (4): 582–93. PMID 7421291.