Pulmonary Valve Area Research Articles

Pulmonary valve morphometry revisited: Clinical implications for valvular and supravalvular interventions.

In this cadaver-based study, we aimed to present a novel approach to pulmonary valve (PV) anatomy, morphometry, and geometry to offer comprehensive information on PV structure. The 182 autopsied human hearts were investigated morphometrically. The largest PV area was seen for the coaptation center plane, followed by basal ring and the tubular plane (626.7 ± 191.7 mm2 vs. 433.9 ± 133.6 mm2 vs. 290.0 ± 110.1 mm2 , p < 0.001). In all leaflets, fenestrations are noted and occur in 12.5% of PVs. Only in 31.3% of PVs, the coaptation center is located in close vicinity of the PV geometric center. Similar-sized sinuses were found in 35.7% of hearts, in the remaining cases, significant heterogeneity was seen in size. The mean sinus depth was: left anterior 15.59 ± 2.91 mm, posterior: 16.04 ± 2.82 mm and right anterior sinus: 16.21 ± 2.81 mm and the mean sinus height: left anterior 15.24 ± 3.10 mm, posterior: 19.12 ± 3.79 mm and right anterior sinus: 18.59 ± 4.03 mm. For males, the mean pulmonary root perimeters and areas were significantly larger than those for females. Multiple forward stepwise regression model showed that anthropometric variables might predict the coaptation center plane (sex, age, and heart weight; R2 =33.8%), tubular plane (sex, age, and BSA; R2 =20.5%) and basal ring level area (heart weight and sex; R2 =17.1%). In conclusion, the largest pulmonary root area is observed at the coaptation center plane, followed by the basal ring and tubular plane. The PV geometric center usually does not overlap valve coaptation center. Significant heterogeneity is observed in the size of sinuses and leaflets within and between valves. Anthropometric variables may be used to predict pulmonary root dimensions.

DELVE FOR THE VALVE MASS: A CASE OF PULMONARY FIBROELASTOMA MIMICKING ENDOCARDITIS

Cardiac papillary fibroelastoma (PFE) are rare and benign tumors of endocardium accounting for 7% of all cardiac tumors. Aortic and mitral valve area are the most common sites of its occurrence and rarely they involve pulmonary valve (PV) area and are typically found incidentally during a open heart

P839 The lucky unlucky patient: a case report

Abstract Introduction Carcinoid tumors are rare neuroendocrine malignancies arising from the neural crest amine precursor uptake decarboxylation cells and are most commonly (90%) located in the gastrointestinal system, the most malignant arising from the ileum. Approximately 50% of patients with carcinoid syndrome will develop carcinoid heart disease, which is commonly characterized by the thickening and retraction of the tricuspid ± the pulmonary valves resulting in significant regurgitation ± stenosis. Hepatic metastasis must be present for the carcinoid heart disease to develop. In order to develop left-sided heart valve lesions, communication between the left and right heart chambers must be present. Case presentation A 50-year-old female patient with a known neuroendocrine tumor of the ileum with hepatic and peritoneal metastasis presented at our facility for evaluation of the heart valves. She was diagnosed with the neuroendocrine tumor in 2017, a resection of the intestinal ileocecal segment and peritoneal nodules was done in the same year (stadium pT3N1M1b ki 67 2%), the tumor was angio and neuroinvasive. The disease was treated with somatostatin analogues with minimal regression of the disease. She started peptide receptor radionuclide therapy and completed 3 cycles. In October 2018 an increment of one of the hepatic lesions was documented, with other hepatic lesions remaining of stable dimensions. Due to the recent appearance of dyspnea in mild to moderate physical activities she was sent to our facility for echocardiography. The transthoracic and transesophageal echocardiography revealed severe tricuspid regurgitation with mild stenosis (tricuspid anatomic area 3.5 cm², max gradient 7 mmHg, mean gradient 4 mmHg) caused by thickened and retracted cusps with a significant coaptation deficit. Severe stenosis and insufficiency of the pulmonary valve was also noted (maximum gradient 22 mmHg, mean gradient 15 mmHg, pulmonary valve area 0.5 cm²), with a rapid deceleration regurgitation jet limited to protodiastole, caused by thickened and retracted pulmonary valve leaflets. The interatrial septum exhibited an aneurysm with a patent foramen ovale (PFO) and mild left-to-right shunt. Despite the shunt left-sided heart valves were not affected, therefore we recommended a replacement of the tricuspid and pulmonary valves with an intraoperative closure of PFO and intraoperative verification of the efficacy of the surgical closure. Conclusion Carcinoid heart disease is an important cardiac complication of the neuroendocrine neoplasms. Communication between the right and left heart chambers (for example a PFO) must be present for the development of left heart valve lesions. Our patient had a PFO with a mild left to right shunt, but fortunately no left sided lesions were found. Abstract P839 Figure. Carcinoid heart disease

Echocardiographic evaluation of velocity ratio, velocity time integral ratio, and pulmonary valve area in dogs with pulmonary valve stenosis.

BackgroundVelocity ratio, velocity time integral (VTI) ratio, and pulmonary valve area indexed to body surface area (iPVA) are methods of assessment of pulmonary valve stenosis (PS) severity that are less dependent on blood flow. Studies evaluating these methods are limited.ObjectivesTo determine the effects of butorphanol, atenolol, and balloon valvuloplasty (BV) on velocity ratio, VTI ratio, iPVA, mean PG, and max PG.AnimalsTwenty‐seven dogs with PS (max PG >50 mm Hg).MethodsProspective study. All dogs underwent an echocardiogram at baseline, 5‐minutes after administration of butorphanol (0.2‐0.25 mg/kg IV), and 2‐to‐4 weeks after atenolol (1‐1.5 mg/kg q12h). Twenty‐one of these were evaluated 24‐hours after BV.ResultsThere were no significant differences (P > .05) amongst any of the methods of assessment of PS severity after butorphanol. After atenolol, mean (SD) of mean (57.0 [21.0] mm Hg) and max PG (93.1 [33.8] mm Hg) were significantly decreased (P ≤ .047) compared with baseline (65.2 [26.2] mm Hg and 108 [44.4] mm Hg, respectively). After atenolol, there were no significant (P ≥ .12) differences in velocity ratio (0.29 [0.09]), VTI ratio (0.18 [0.05]), or iPVA (0.43 [0.16] cm2/m2) compared with baseline (0.30 [0.09], 0.19 [0.09], 0.44 [0.17] cm2/m2, respectively).Conclusions and Clinical ImportanceAtenolol might reduce mean and max PG but does not alter less flow‐dependent methods of assessment of PS severity (velocity ratio, VTI ratio, and iPVA) in dogs with PS. Results support an integrative approach to assessment of PS severity that includes less flow‐dependent methods, particularly in states of altered flow or right ventricular function.

Right and left atrial appendage function in patients with mitral stenosis and sinus rhythm

Tissue Doppler imaging (TDI) is generally used for the assessment of ventricular function, and to a lesser extent, to evaluate the left atrial appendage (LAA). In the present study, we used TDI to analyze the contractile function of the right atrial appendage (RAA). The aim of this study was a comprehensive evaluation of RAA and LAA contractile function in patients with mitral stenosis and sinus rhythm. A total of 69 patients were assessed: group 1 (23 patients with severe MS, 38 +/- 11 years, 20 women), group 2 (23 patients with mild MS, 39 +/- 12 years, 19 women) and group 3 (23 healthy subjects, 42 +/- 14 years, 16 women). Multiplane transesophageal echo was performed in all patients. The RAA was visualized at 130 degrees and the LAA at 0 degrees . TDI sample volume was placed in the tip of both atrial appendages, with an ultrasound beam angle < 10 degrees . Flow velocities and myocardial velocities were measured. The presence of thrombus and/or spontaneous echo contrast (SEC) was assessed. TDI showed in normal subjects, myocardial contraction velocities in RAA similar to that of the LAA (21.8 +/- 4.2 vs. 20.1 +/- 4 cm/s, respectively, P = NS). In patients with MS, myocardial velocities in both atrial appendages were significantly lower than in normal subjects (RAA: 17.4 +/- 5.1 vs. 21.8 +/- 4.2 cm/s, respectively, P < 0.01, LAA: 9 +/- 5.1 vs. 20.1 +/- 4 cm/s, respectively, P < 0.001). Linear regression analysis showed a correlation between the impairment of systolic function of both appendages, pulmonary arterial pressure, valve area and transmitral gradient. Of the 46 patients with MS, patients with intense SEC had lower flow and myocardial velocities in the LAA than patients without SEC (16 +/- 5 vs. 50 +/- 3 cm/s, 6 +/- 2 vs. 10.6 +/- 5.6 cm/s, respectively, P < 0.001 and P < 0.001). In healthy subjects, myocardial contraction velocities in both appendages were similar. Patients with MS and sinus rhythm had contractile dysfunction of both appendages, shown by the decrease in myocardial velocities and related to the increase in atrial afterload. Both appendages exhibited a relation between contractile dysfunction and the presence of SEC, but dysfunction was less marked in the RAA, which might explain the lower prevalence of thrombi in the RAA.

Delayed Improvement in Valve Hemodynamic Performance After Percutaneous Pulmonary Valve Implantation

We report the case of a 21-year-old woman with a severely stenotic pulmonary homograft who underwent percutaneous pulmonary valve implantation, with no significant change in transvalvular gradient within the 24 hours after the procedure. Major improvement in hemodynamic valve performance of more than 60% decrease in transvalvular gradient and more than 30% increase in pulmonary valve area was observed 3 months after the procedure, showing that hemodynamic improvement can occur late after pulmonary valve implantation. An echocardiogram after 3 months should be done before concluding the procedure failed and that reintervention is necessary.

Body surface area as a predictor of aortic and pulmonary valve diameter

Background: Predicting cardiac valve size from noncardiac anatomic measurements would benefit pediatric cardiologists, adult cardiologists, and cardiac surgeons in a number of decision-making situations. Previous studies correlating valve size with body size have been generated with the use of fixed autopsy specimens, angiography, and echocardiography, but primarily in the young. This study examines the relation of body surface area to measurements of the left ventricular–aortic junction (aortic valve anulus diameter) and the right ventricular–pulmonary trunk junction (pulmonary valve anulus diameter) in 6801 hearts across a wide spectrum of ages. Methods: From June 1985 to October 1998, cardiac valves from 6801 donated hearts were analyzed morphologically. Donor age was newborn to 59 years (mean 31 ± 17 years; median 32 years). Calculated body surface areas ranged from 0.18 to 3.55 m 2. Aortic (n = 4636) and pulmonary valve diameters (n = 5480) were measured from enucleated valves suitable for allograft transplantation. Mean valve sizes were computed for ranges in body surface area in 0.1-m 2 increments. Results: For adult men (age ≥ 17 years), the mean aortic valve diameter was 23.1 ± 2.0 mm (n = 2214) and the mean pulmonary valve diameter was 26.2 ± 2.3 mm (n = 2589). For adult women, the mean aortic valve diameter was 21.0 ± 1.8 mm (n = 1156) and the mean pulmonary valve diameter was 23.9 ± 2.2 mm (n = 1408). The mean indexed aortic valve area was 2.02 ± 0.52 cm 2/m 2 and the pulmonary valve area 2.65 ± 0.52 cm 2/m 2. Between 82% and 85% of the variability was explained by the size of the patient. Regression equations were developed both overall and separately for men and women, although the additional contribution of sex above that of body size was less than 1%. Conclusions: Aortic and pulmonary valve diameters are closely related to body size. Thus, body surface area, when used in conjunction with other clinically accepted evaluations, is a useful tool for estimating normal aortic and pulmonary valve size. (J Thorac Cardiovasc Surg 2000;119:975-82)

Prevalence and clinical importance of heart murmurs in racehorses.

To determine the prevalence of various types of heart murmurs in Thoroughbred racehorses and assess their association with performance by echocardiography and review of the horses' race records for the preceding 2 years. Clinical and retrospective study. 846 Thoroughbred racehorses. Cardiac auscultations were performed by 3 individuals; for 30 horses, Doppler echocardiographic examinations were also performed. Statistical analyses of race records for 753 horses were performed to assess association of heart murmurs with performance. Heart murmurs were detected by cardiac auscultation in 686 of 846 (81.1%) horses. Systolic murmurs over the heart base were most common; 365 (43.1%) horses had systolic murmurs that were loudest over the pulmonary valve area, and 232 (27.4%) horses had systolic murmurs that were loudest over the aortic valve area. Systolic murmurs over the tricuspid valve area were detected in 241 (28.5%) horses, whereas systolic murmurs over the mitral valve area were detected in only 32 (3.8%) horses. Diastolic murmurs were much less common than systolic murmurs. Review of race records did not reveal a significant association between murmurs and performance. Results suggest that heart murmurs are a common finding in racehorses; most of these heart murmurs do not appear to be clinically important.

Resultados a longo prazo da reconstrução da via de saída do ventrículo direito com monocúspide porcina

O beneficio hemodinâmico e funcionamento tardio das monocuspides implantada na via de saida do ventriculo direito sao pontos que continuam controversos na literatura. Com o objetivo de se estudar o comportamento tardio de uma monocuspide porcina montada em remendo de pericardio bovino, 45 pacientes selecionados, portadores de diversos tipos de cardiopatia congenita operados entre junho de 1989 e abril de 1996, foram acompanhados ate dezembro de 1996. A idade variou de 2 semanas a 18 anos (media 4,8 ± 4,7 anos). Ocorreram 5 obitos hospitalares, diretamente relacionados a condicao clinica pre-operatoria e a complexidade da doenca. Com 3 pacientes nao tendo sido encontrados para acompanhamento, 37 foram seguidos por um periodo que variou de 6 a 90 meses (media 4,8 ± 19,0 meses). Nao houve mortalidade tardia. Dois pacientes foram reoperados, sendo o primeiro apos 24 meses devido a insuficiencia pulmonar grave em crianca portadora de sindrome da valva pulmonar ausente e o segundo apos 23 meses devido a estenose pulmonar infundibular residual. A reoperacao, os enxertos mostravam-se bem conservados e sem sinais de calcificacao, o que foi confirmado pelos estudos histologicos das pecas retiradas. O segundo paciente recebeu uma nova monocuspide. Os demais 35 pacientes encontram-se assintomaticos. Trinta e seis pacientes tem sido avaliados periodicamente, atraves de ecocardiogramas seriados. A monocuspide permanece movel e funcionante em todos os casos, sem sinais de calcificacao, estenose ou dilatacao. O gradiente sistolico medio de pico atraves da via de saida do ventriculo direito tem sido de 19,0 ± 5,8 mmHg. Regurgitacao pulmonar esta ausente em (33%) 12 pacientes, e leve em 15 (42%) e moderada em 9 (25%). Em conclusao, a monocuspide porcina apresenta excelente desempenho hemodinâmico a longo prazo, sem evidencias de estenose tardia. Apresenta-se funcional e sincronica com o ciclo cardiaco ate 7 anos apos o implante.

Feasibility study of vascular-endoscopic valvuloplasty. Using a laser and flexible endoscope.

Percutaneous balloon valvuloplasty is generally accepted, but post procedural complications limit its efficacy and reduce long-term success. To eliminate these risks, the authors explored the feasibility of cardioscopy guided percutaneous laser valvuloplasty in an experimental setting. The combined working model consisted of a separate balloon tipped thin fiber optic endoscope, laser balloon catheter, and a Nd-YAG laser transmitter. A porcine pulmonary valve was used as our in vivo target of laser ablation in a beating heart. Under general anesthesia, the endoscopic catheter is delivered into the pulmonary valve area through either the internal jugular or femoral vein under fluoroscopy. Positioning the pulmonary apparatus coaxial to the endoscopic visual field by manipulation of the catheter allowed for targeting and ablation of the commissure of the pulmonary valve under endoscopic view through the balloon filled with saline solution. The ablation energy was 15-30 W, 0.5-1.0 sec, and 2,000-3,000 J total. The animal was then killed and histopathologic study of the ablated area was done. The commissure of the pulmonary valve was smoothly ablated in 4 cases, and the entire ablation procedure was successfully witnessed through endoscopy. The authors encountered some difficulty in laser targeting, limitations to the endoscopic field of vision, and difficulty in holding the position of the apparatus in the beating heart. These are the barriers to overcome for future clinical application of this procedure. However, these results indicate the clear possibility of future use of cardioscopy guided percutaneous laser valvuloplasty in a clinical setting.

Balloon mitral commissurotomy in patients aged ≥70 years

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were ≥70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p < 0.007) and atrial fibrillation (61 vs 36%; p < 0.0001), and had a higher echocardiographic score (9.3 ± 2 vs 8 ± 1.6; p < 0.0004) and a lower baseline cardiac index (2.1 ± 0.6 vs 2.4 ± 0.6 liters/min/m 2; p < 0.03) than younger ones. Baseline mean pulmonary pressure (37 ± 11 vs 34 ± 12 mm Hg), transmitral gradient (14 ± 4 vs 14 ± 5 mm Hg) and valve area (1.0 ± 0.4 vs 1.1 ± 0.3 cm 2) were not different between older and younger patients (p = NS). Acute complications during the procedure (including cardiac perforation, embolism, severe mitral regurgitation and surgical atrial shunt), and 30-day mortality after BMC were more frequent in older than younger patients (27 vs 9% [p < 0.01], and 12 vs 0.8% [p < 0.005], respectively). A complete success, defined as a mitral valve area increase >25% and postmitral valve area >1.5 cm 2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1). At 6 months, 20 of the 21 surviving patients (95%) who had not crossed over to surgery had an improvement of ≥1 functional class, and 13% remained improved after a mean follow-up of 28 ± 17 months. Long-term survival of older patients was compared with that of our first 96 younger ones dilated before 1990. The total survival rate at 3 years was 70% in older patients and 92% in younger ones (p < 0.001). Thus, BMC can be an effective therapy for parents aged ≥70 years, but has an increased risk of morbidity and mortality compared with in younger ones. However, the hemodynamic success rate in patients aged ≥70 years with the completed procedure, and the long-term cardiac survival in those with a good initial result are similar to those in younger ones. Therefore, BMC can be performed in older patients with an acceptable risk compared with that of medical treatment or surgery.

Echocardiographic determination of aortic and pulmonary valve areas in subjects with normal hearts

Two-dimensional and Doppler echocardiography were performed in 70 subjects (aged 1 day to 16 years, body surface area from 0.08 to 2.1 m 2) to determine aortic and pulmonary valve areas in normal children and adolescents. Valve areas were determined by the continuity equation using echo-determined ventricular outflow tract diameters and Doppler-determined flow velocities from the outflow tracts and corresponding great arteries. Left ventricular outflow tract diameter ranged from 0.3 to 2.2 cm and right ventricular outflow tract diameter from 0.4 to 2.8 cm. Outflow tract diameters were linearly related to the square root of body surface area. Flow velocity increased from a mean of 0.75 m/s in the left ventricular outflow tract to 1.12 m/s in the aorta and from 0.56 m/s in the right ventricular outflow tract to 0.89 m/s in the pulmonary artery. Flow velocities were unrelated to body size. Valve areas were linearly related to body surface area (r = 0.88 and 0.80 for the aortic and pulmonary valves, respectively). Mean aortic and pulmonary valve area indexes were 1.33 cm 2/m 2 and 1.70 cm 2/m 2, respectively. The data provide normal values for echocardiographically determined valve areas and validate the practice of indexing valve area for body surface area.

Rest and exercise hemodynamics in pulmonary stenosis: comparison of children and adults

To better understand the hemodynamics of pulmonary stenosis (PS), 24 adults and 53 children with similar degrees of PS who had undergone cardiac catheterization at rest and during supine exercise were retrospectively studied. Three groups were defined. Group I consisted of 9 adults and 18 children with a pulmonary valve area of less tjan 0.5 cm 2/m 2; group II, 6 adults and 25 children with a pulmonary valve area of 0.5 to 1.0 cm 2/m 2; and group III, 9 adults and 10 children with pulmonary valve area of more than 1.0 cm 2/m 2. The mean ages of the adults were 29, 26 and 22 years for groups I, II, and III, respectively. The mean ages of the children were 11, 10 and 9 years for groups I, II and III, respectively. The pertinent data collected from catheterization included oxygen consumption, cardiac rate and index, arterial venous oxygen difference, stroke index, right ventricular (RV) systolic pressure and RV end-diastolic pressure. Adults and children in groups II and III had a appropriate response to exercise. Group I children responded abnormally by increasing their RV end-diastolic pressure and decreasing their stroke index. In group I adults both of these variables increased. Group I adults exhibited a significantly lower cardiac index at rest and exercise secondary to a significantly lower absolute cardiac rate. Long-standing severe PS results in hemodynamic compromise. Hence, early relief of PS is recommended.

LONG-TERM RESULTS OF BALLOON VALVULOPLASTY OF THE PULMONARY VALVE

The long-term efficacy of transluminal balloon valvuloplasty (val) was evaluated in 7 children (age 1.5-9.9 yrs) with pulmonary stenosis 1 yr post-val. Prior to, immediately (Imm) post-val and at 1 yr post-val, the following parameters were evaluated at cath: pulmonary artery (PA), right ventricular (RV) and aortic pressures, heart rate (HR), pulmonary blood flow (PBF) and pulmonary valve area (PVA); ECG, vectorcardiogram (VCG) and doppler echocardiogram were performed.One yr post-val, RV-PA gradient and R V press decreased further from Imm post-val values in 6/7 pts. In addition, there was also an increase in both PBF and PVA over Imm post-val values. Although the ECG only mildly improved 1 yr post-val (R in V1 decreased from 13±2 to 11±4 mm), the VCG significantly improved with a decrease in right maximal spatial voltage (2.0±.9 to 1.1±.4 mV, p<.05) and a loss of the clockwise horizontal loop in all pts. Pulmonary regurgitation was present at 1 yr post-val (auscultation 2/7; doppler 6/7). Inferior vena cava thrombosis occurred in 1 pt. Balloon val appears to be an effective, safe method for producing long term relief of valvar pulmonary stenosis.

Percutaneous balloon valvuloplasty for treatment of congenital pulmonary valvular stenosis in children

Percutaneous balloon pulmonary valvuloplasty was performed in seven children with moderate to severe valvular pulmonary stenosis (right ventricular to pulmonary artery pressure gradient greater than 50 mm Hg). All patients experienced a decrease in right ventricular peak systolic pressure from 108 +/- 30 to 60 +/- 5.6 mm Hg (p less than 0.001), decrease in right ventricular to pulmonary artery gradient from 90.1 +/- 30 to 38.8 +/- 5 mm Hg (p less than 0.001) and increase in pulmonary valve area from 0.33 +/- 0.06 to 0.55 +/- 0.15 cm2/m2 (p less than 0.001). In the two patients who underwent supine bicycle exercise before and after valvuloplasty, a significant decrease in both the maximal right ventricular peak systolic pressure (212 to 140 and 175 to 125 mm Hg, respectively) and in right ventricular to pulmonary artery peak pressure gradient (185 to 110 and 151 to 85 mm Hg, respectively) occurred. All patients tolerated the procedure well and no serious complications were observed. It is concluded that percutaneous balloon valvuloplasty is a safe and effective method for relief of right ventricular obstruction due to moderate or severe valvular pulmonary stenosis. However, long-term results remain unknown.

Letter: Calculating pulmonary valve area.

HomeCirculationVol. 51, No. 5Letter: Calculating pulmonary valve area. Free AccessAbstractPDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessAbstractPDF/EPUBLetter: Calculating pulmonary valve area. S Wolfson S WolfsonS Wolfson Search for more papers by this author Originally published1 May 1975https://doi.org/10.1161/01.CIR.51.5.950Circulation. 1975;51:950"Letter: Calculating pulmonary valve area.." Circulation, 51(5), p. 950 Previous Back to top Next FiguresReferencesRelatedDetails May 1, 1975Vol 51, Issue 5Article InformationMetrics Copyright © 1975 by American Heart Associationhttps://doi.org/10.1161/01.CIR.51.5.950 Originally publishedMay 1, 1975 PDF download Advertisement

Regression of valvular pulmonary stenosis.

Eight patients with mild to moderate valvular pulmonary stenosis underwent serial physiological studies before surgical intervention. Average pulmonary valve area at the initial study was 0.59 cm.2 and at the second study (average 7.8 years later) was 1.09 cm.2, resulting in an average increase of 0.49 cm.2 (p greater than 0.05). In normal subjects during early years the pulmonary valve area increases linearly with age and with increasing body surface area. Though patients with valvular pulmonary stenosis have smaller valve orifices, they also show an increase in valve size with increasing age and with increasing body growth. The greatest increase in valve area was observed in 4 patients (all under age 6) in whom body surface area increased more than 70 per cent.

The natural history of pulmonary valvular stenosis: Serial cardiac catheterizations in 21 children

In an attempt to study the natural history of isolated pulmonary valvular stenosis, 21 children with serial cardiac catheterizations were reviewed. The clinical, electrocardiographic, and roentgenographic features in the majority of these cases did not suggest that there had been a change in the severity of the pulmonary stenosis during the interval of study. In 19 of the 21 cases the right ventricular systolic pressure remained in the same range over the period of observation. Of the 17 cases in which complete data were available, 16 exhibited an increase in the pulmonary valve area, which was in proportion to the increase in body growth. It is concluded that the increasing severity of pulmonary valvular stenosis that has been reported is due not to a failure of the pulmonary valve orifice to increase in size as the child grows, but rather possibly to factors of infundibular hypertrophy or myocardial fibrosis.

Changes with age of the pulmonary valve area in children with pulmonary valvular stenosis

osmotic pressure was measured by osmometry. The pulmonary extravascular water volume was obtained from the difference between the volumes of dilution of T-1824 and tritiated water injected simultaneously into the pulmonary artery and sampled from the aorta; it was measured in duplicate before and at the end of the test period. The total lung water was determined at autopsy by drying. Water loss through pulmonary lymph flow was assessed by surgically obstructing right lymphatic duct drainage. At transcapillary gradients of 10.0 to 17.4 mm. Hg (8 dogs) extravascular water accumulated at an average rate of 1.0 ml. per kilogram body weight per hour per 10 mm. Hg gradient: following lymphatic obstruction (9 dogs) the filtration rate at similar gradients was 1.4 ml. per kilogram per hour per 10 mm. Hg. At gradients of 21.6 to 32.5 mm. Hg (5 dogs) lung water accumulated at an average rate of 4.1 ml. per kilogram per hour per 10 ram. Hg gradient. In these experiments obstructing the right lymphatic duct was without influence on the development of acute puhnonary edema, The difference in filtration rates at the low and high gradients suggests either that the lung developed a positive tissue pressure resisting edema formation at the low gradients, or that capillary permeability was increased at the high gradients.

ACCURACY OF THE PHONOCARDIOGRAM IN ASSESSING SEVERITY OF AORTIC AND PULMONIC STENOSIS.

A critical evaluation was made of the reliability of three easily obtainable phonocardiographic criteria in the estimation of ventricular peak pressure in congenital pulmonic and aortic valvular stenosis. In 50 patients with pulmonic stenosis the Q-ejection click interval showed a significant inverse relationship to peak pressure (r=–0.77, p &lt;0.001), while no significant relationship existed in aortic stenosis (r = 0.40, p &lt;0.5). The timing of the peak magnitude of the murmur again related significantly to the right ventricular pressure (r = 0.72, p &lt; 0.001) and with the log of pulmonary valve area (r=–0.72, p &lt;0.001). In contrast no significant relationships existed in aortic stenosis. The degree of splitting also reflected the severity of right ventricular hypertension (r = 0.84, p &lt;0.001), while this measurement in aortic stenosis proved quite variable and did not reflect ventricular peak pressure. The significance of a combination of these criteria in predicting the severity of right ventricular hypertension and in obviating the need for cardiac catheterization is stressed. An explanation for the mechanism underlying the observed changes is given. Q-ejection click interval in particular constitutes an indirect but sensitive way (r =–0.90, p &lt; 0.001) of estimating the rate of pressure development (dp/dt) in the hypertrophied right ventricle.