Echocardiographic Detection of Associated Pulmonary and Mitral Valve Prolapse

Abstract

To the Editor Combined valvular prolapse is being discovered with increasing frequency since echocardiography allows noninvasive analysis of valvular motion. Recently, Ogawa and coworkers1Ogawa S Hayashi J Sasaki H et al.Evaluation of combined valvular prolapse syndrome by two-dimensional echocardiography.Circulation. 1982; 65: 174-180Crossref PubMed Scopus (35) Google Scholar reported a series of 50 patients with mitral valve prolapse; in one case of combined mitral and tricuspid valve prolapse, pulmonary regurgitation could be assessed by intracardiac phonocardiography. Even though pulmonary valve involvement by myxomatous degeneration has been described,2Frable WJ Mucinous degeneration of the cardiac valves; the “floppy valve” syndrome.J Thorac Cardiovasc Surg. 1969; 58: 62-70PubMed Google Scholar only one case of pulmonary valvular prolapse has been studied echocardiographically in a patient with pulmonary valve endocarditis.3Nakamura K Suzuki S Sakakibara S Komatsu J Takahashi S Hirosawa K M-mode and cross sectional echocardiographic features of flail pulmonary valve. A case report.Jpn Heart J. 1980; 21: 897-902Crossref PubMed Scopus (6) Google Scholar A 49-year-old man underwent echocardiographic study for evaluation of a grade 2/6 systolic murmur, followed by a soft grade 2/6 diastolic murmur, best heard in the second left intercostal space. ECG and chest x-ray examination did not show any abnormality. Two-dimensional echocardiography demonstrated an unusually large diastolic motion of the pulmonic cusps. Using a parasternal long axis view, with superolateral angulation of the probe, the right ventricular outflow tract and the main pulmonary artery could be seen, separated by two cusps of the pulmonic valve. Figure la allows clear observation of protrusion of two pulmonic cusps into the right ventricular outflow tract during diastole. The M-mode tracing demonstrated a particularly steep E-F slope with coarse and undulating movements during diastole (Fig 1b). In addition, the inferior cusp produced multiple echoes, consistent with local redundant material. On apical four-chamber view, the anterior and posterior mitral leaflets showed a systolic bulging into the left atrium, consistent with mild mitral valve prolapse. Further analysis of M-mode and two-dimensional echocardiogram did not detect any other abnormality. In this patient, the usual possible causes of pulmonary regurgitation could be reasonably ruled out. Because of the presence of associated mitral valve prolapse, we suggest that the most probable origin was myxomatous degeneration of the pulmonary valve. As pathologic examination has demonstrated that myxomatous degeneration may involve the four cardiac valves,2Frable WJ Mucinous degeneration of the cardiac valves; the “floppy valve” syndrome.J Thorac Cardiovasc Surg. 1969; 58: 62-70PubMed Google Scholar the rare occurrence of pulmonary valve prolapse can be questioned. Clinically, isolated pulmonary regurgitation is often asymptomatic and its diastolic murmur is usually faint and difficult to detect. Moreover, the pulmonary valve often remains uneasy to record echocardiographically. Finally, the pulmonary valve is submitted to the lowest pressure stress among the four cardiac valves. As the transvalvular pressure gradient, as well as the size of the cusps and the stage of tissue alteration play probably a synergistic role to determine the prolapse, it is conceivable that, even if the morphologic changes were uniform on the four valves, the pulmonary valve would be the last one to present a prolapse. This case illustrates, in addition, a particular M-mode echo pattern of pulmonary valve motion in pulmonary regurgitation, different from those described earlier by Weyman and coworkers4Weyman AE Dillon JC Feigenbaum H Chang S Pulmonary valve echo motion in pulmonary regurgitation.Br Heart J. 1975; 37: 1184-1190Crossref PubMed Scopus (10) Google Scholar who found irregular and undulating movements of cusps during diastole. We suggest that a similar M-mode echo pattern should be carefully screened by two-dimensional echocardiography, using appropriate parasternal views, for the presence of pulmonary valve prolapse.