Pulmonic regurgitation differential diagnosis

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

Pulmonic regurgitation (PR) must be differentiated from other diseases that cause blowing decrescendo murmur such as aortic regurgitation. 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.

Differential diagnosis of pulmonic regurgitation

Pulmonic regurgitation (PR) must be differentiated from other diseases that cause blowing decrescendo murmur such as aortic regurgitation. The diseases which may present with overlapping symptoms as pulmonic regurgitation may include the following:

Disease	Findings
Aortic Regurgitation	Patients present with dyspnea and fatigability as a consequence of reduced cardiac reserve in the fourth or fifth decade AR murmur is heard over left sternal border or over the right second intercostal space and radiates to the neck
Tricuspid Regurgitation causing right vetricular enlargement	Pansystolic murmur accentuating with inspiration RV heave Gaint "V" wave seen on JVP examination Hepatomegaly is seen in 90% of patients Quantification of severity of TR is done by colour flow doppler imaging
Left to Right Shunt causing RV enlargement	Usually seen in children with acyanotic congenital disease such as ASD Fixed splitting of S2 is present
Arrhythmogenic Right Ventricular Cardiomyopathy	Gradual replacement of normal functional myocardium with adipose or fibroadipose tissue Age of onset is 7 to 40years Patients are usually asymptomatic, present with occasional palpitations EKG shows negative "T" waves and epsilon waves with selective ""S" wave delay in V1 to V3 RV is dilated and hypokinetic on echocardiography Holter monitoring helps to diagnose hyperkinetic ventricular arrythmias

Other differential diagnosis

• Pulmonary hypertension
• Infective endocarditis
• Rheumatic heart disease
• Congenital abnormalities: tetralogy of Fallot, ventricular septal defect, valvular pulmonic stenosis
• Carcinoid heart disease (the majority of patients with metastatic disease will have both pulmonic stenosis and pulmonic regurgitation)
• Marfan syndrome
• Syphilis infection
• Trauma from withdrawing a Swan-Ganz catheter with the balloon inflated
• Following valvuloplasty of pulmonary stenosis
• Absence of the pulmonic valve
• Fenestrations in or redundant leaflets of the pulmonic valve