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], Javaria Anwer M.D.[4]
Overview
The history and clinical presentation of pulmonary regurgitation (PR) vary with the cause of the regurgitation and right ventricular dysfunction. The patient may present with a history related to the primary cause of PR. Isolated pulmonary regurgitation is usually asymptomatic. However, patients with chronic PR may present with symptoms of heart failure such as dyspnea on exertion, fatigue, ankle edema, hemoptysis, nocturnal cough and palpitations. Smoking or intravenous drug use (recreational) history are important to assess the cause fo PR.
History
Patient history
- The patient history is highly dependant upon the etiology and severity of PR. The patient may present with a history related to the primary cause of PR.
- Decreased exercise tolerance or easy fatigability 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 tiredness and abdominal fullness/bloating, and leg swelling.[1]
- Mild PR[2]: The majority of patients with mild PR are asymptomatic and may never present with any history related to PR.
- 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[1]: A patient may never present with PR related symptoms and the condition is tolerated for years. A patient in his 40s may present with a history of the appearance of symptoms of RV volume overload recently, that was tolerated for many years.
- 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)[1]: 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.
- 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 complications.
- History of symptoms and signs such as flushing, diarrhea, and bronchospasm should draw attention to carcinoid syndrome as high clinical suspician. is required for the diagnosis.[3]
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] IV drug abuse is one of the minor Modified Duke Criteria for the diagnosis of IE.[8]
Allergies
- A history of allergy to certain medications such as penicillin, heparin, and anesthetic medications is an important patient management consideration.
- Allergy to certain 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. alpha-gal allergy leading to premature degeneration of the aortic valve bioprosthesis has been reported. [9]
Common symptoms
- The clinical presentation of pulmonary regurgitation varies with the cause of the regurgitation and the right ventricular function.[10]
- 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. The common presenting symptoms due to heart failure in descending order of prevalence include[2][11][12][13][14][15]:
- Dyspnea on exertion/ exercise intolerance or limitation of physical activity. (may be due to pulmonary edema or among patients with suboptimal cardiac output).
- Orthopnea (due to pulmonary edema)
- Fatigue
- Ankle edema or swelling of the feet and legs (fluid retention due to suboptimal cardiac pumping action)
- Nocturnal cough (due to pulmonary edema)
- Hemoptysis or frothy sputum (due to pulmonary edema)
- Light-headedness (suboptimal cardiac output received by the brain usually due to left heart failure)
- Chest pain (due to pulmonary edema)
- Hepatic congestion leads to hepatomegaly and may present as:
- Early satiety
- Abdominal distension (maybe due to ascites or hepatomegaly)
- At an early stage of RV dysfunction, the patients often fall in NYHA class 1 although symptoms may vary for a few patients.[13]
- Patients with arrythmias present with palpitations, dizziness, or an episode of syncope.[16][17]
Associated symptoms
PR is a secondary disease and it is important to assess the causative lesion. Symptoms of the underlying 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.
- To read about the symptoms and history of PAH, click here.
References
- ↑ 1.0 1.1 1.2 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.
- ↑ 2.0 2.1 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.
- ↑ Fox DJ, Khattar RS (October 2004). "Carcinoid heart disease: presentation, diagnosis, and management". Heart. 90 (10): 1224–8. doi:10.1136/hrt.2004.040329. PMC 1768473. PMID 15367531.
- ↑ 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.
- ↑ Holland TL, Baddour LM, Bayer AS, Hoen B, Miro JM, Fowler VG (September 2016). "Infective endocarditis". Nat Rev Dis Primers. 2: 16059. doi:10.1038/nrdp.2016.59. PMC 5240923. PMID 27582414.
- ↑ Hawkins RB, Frischtak HL, Kron IL, Ghanta RK (July 2016). "Premature Bioprosthetic Aortic Valve Degeneration Associated with Allergy to Galactose-Alpha-1,3-Galactose". J Card Surg. 31 (7): 446–8. doi:10.1111/jocs.12764. PMC 5013262. PMID 27238083.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.
- ↑ 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.
- ↑ Khavandi, Ali (2014). Essential revision notes for the cardiology KBA. Oxford: Oxford University Press. ISBN 978-0199654901.
- ↑ 13.0 13.1 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.
- ↑ Inamdar AA, Inamdar AC (June 2016). "Heart Failure: Diagnosis, Management and Utilization". J Clin Med. 5 (7). doi:10.3390/jcm5070062. PMC 4961993. PMID 27367736.
- ↑ Watson RD, Gibbs CR, Lip GY (January 2000). "ABC of heart failure. Clinical features and complications". BMJ. 320 (7229): 236–9. doi:10.1136/bmj.320.7229.236. PMC 1117436. PMID 10642237.
- ↑ 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.