Journal of Postgraduate Medicine
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Year : 1979  |  Volume : 25  |  Issue : 4  |  Page : 219-223  

Pulmonary valve echocardiography

SG Karmarkar 
 Department of Cardiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Bombay-400 012, India

Correspondence Address:
S G Karmarkar
Department of Cardiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Bombay-400 012


Pulmonary valve echocardiography has been done in 11 cases of pulmonary hypertension, and 4 cases of right ventricular outflow tract obstruction, either at valvar, infundibular or combined level. Absence of `a«SQ» wave was noted in 6 out of 10 cases in whom dia­stolic gradient across the pulmonary valve was more than 25 mm of mercury. Accelerated «SQ»bc«SQ» slope was found in all the 11 cases of pulmonary hypertension. Two patients had negative and 6 had flat `ef«SQ» slopes. Remaining 3 patients had normal «SQ»ef«SQ» slope despite hav­ing moderately severe pulmonary hypertension. Only three of our patients had shown midsystolic closure and fluttering of pulmonary valve. In right ventricular outflow tract obstruction one patient with valvar and infundibular stenosis had shown presystolic opening of the pulmonary valve with fluttering of the leaflets during systole. Three other patients had no remarkable features.

How to cite this article:
Karmarkar S G. Pulmonary valve echocardiography.J Postgrad Med 1979;25:219-223

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Karmarkar S G. Pulmonary valve echocardiography. J Postgrad Med [serial online] 1979 [cited 2020 Nov 29 ];25:219-223
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Methods of detection of pulmonary valve have already been described. [1] Nor­mal pulmonary valve echogram is illus­trated in [Figure 1] (see on page 218 B).

The purpose of this study is to estab­lish the usefulness of the echo pattern of pulmonary valve in the diagnosis of pul­monary hypertension and pulmonary ste­nosis.

 Material and Methods

Clinical material consisted of 15 patients in whom pulmonic valve was recorded by echocardiography prior to cardiac cathe­terization. There were 11 males and 4 females. Their ages ranged from 4 to 48 years, the average age being 19 years. There were 11 cases of pulmonary hyper­tension and 4 cases of pulmonary ste­nosis.

The 11 cases of pulmonary hyperten­sion were of diverse etiology [Table 1].

All patients in this group except one had mean pulmonary artery pressure above 40 mm Hg.

Atrial fibrillation was present in one case.

Out of four cases of pulmonary steno­sis, one had infundibular-valvar steno­sis, one case had isolated infundibular stenosis. The third patient was a case of infundibular stenosis and ventricular septal defect and the last patient was a case of valvar and infundibular pulmonary stenosis with ventricular septal defect. Two of these four cases had severe out­flow obstruction (gradient > 100 mm Hg.) and the remaining two had mode­rate obstruction (gradient 50 to 100 mm Hg.).

Echocardiographic examination was performed with a Unirad Sonograph with a Honeywell Fibreoptic model 1858, strip chart recorder. A 2.25 mHz transducer with 10 mm. outer diameter focussed at 7.5 cms. was used. The method already in use for recording pulmonary valve was followed.' All tracings were initially re­corded at a paper speed of 25 mm/sec. followed by 100 mm/sec.


Pulmonary Hypertension:

(1) `a' wave: Sinus rhythm was present in ten out of eleven cases. In these ten patients mean Amax was 1.2 mm. (0-5 mm); `a' wave was absent in six of these ten patients. In two cases it was 5 mm., in one 3 mm. and in the remaining patient it was 1 mm.

It was observed that patients with dia­stolic gradient of more than 25 mm. across the pulmonary valve had `a' wave less than 1 mm (See [Figure 2] below).

(2) be Slope (rate of systolic opening).

This rate of systolic opening of pulmon­ary, valve ranged from 342-586 mm/sec. with .- a mean of 443 mm/sec. It was ob­served that all the eleven patients had increased `be' slope (See [Figure 3] on page 221).

(1) be Amplitude (systolic opening am­plitude).

The mean amplitude of leaflet opening was 15.5mm . with a range of 12-17 mm. There was no correlation between the mean pulmonary artery pressure and the leaflet opening amplitude.

(2) Midsystolic closure and fluttering:

Midsystolic closure (See [Figure 4] on page 218 B) was present in 3 out of 11 cases of pulmonary hypertension. In all these 3 cases, mean pulmonary artery pressure was above 65 mm Hg. Two of these three patients also showed 'cd' segment flutter­ing. Three more patients showed 'cd' segment fluttering in whom the mean pul­monary artery pressure was > 50 mm Hg.

(3) Right ventricular performance­ (RPEP : RVET)

The ratio of RPEP and RVET which reflects the right ventricular performance was 0.21 (mean) with a range from 0.14 to 0.30.

(4) of Slope: -

There was no relationship between the 'ef' slope and the mean pulmonary artery `pressure.

Pulmonary Stenosis:

In the patient with both valvular and infudibular stenosis (B.D.) Amax was 7 mm with no systolic opening as the valve was wide open at the beginning of systole. Hence it has demonstrated premature diastolic opening (See [Figure 5] on page 218 B). It also showed coarse `cd' segment fluttering. Gradient across the pulmonary valve in this case was 200 mm Hg.

The second patient (V.K.) with isolated infundibular pulmonary stenosis and a gradient across the outflow tract of 70 mm Hg. had Amax of 4 mm. and the `b' point returned to the base lane before ins­cribing the `be' slope. There was no 'cd' segment flutter.

An eleven year old boy (R.N.) having infundibular stenosis and ventricular sep­tal defect had gradient across the outflow tract of 75 mm Hg. Amax in this patient was 7 mm. and `b' point returned to semi­closed position. The `be' amplitude was 3 mm. and there was no 'cd' segment flut­tering.

The last patient (G.G.) with valvar and infundibular pulmonary stenosis and ventricular septal defect had gradient across the outflow tract of 190 mm Hg. Amax in this patient was 5 mm. The `b' point returned back to semiclosed po­sition with 'be' amplitude of 3 mm. There was no `cd' segment fluttering.


Pulmonary Hypertension:

`a' wave of the pulmonary valve echo­gram represents a movement of the valve cusps towards open position and it is as a response to the low pressure events in the right ventricle associated with atrial systole. in pulmonary hypertension when the valve cusp is tense in diastole due to increased pulmonary artery end diastolic pressure, deflection due to atria: systole is reduced or eliminated depending on the degree of hypertension. Our findings in this series with regard to `a wave magnitude are consistent with the observations previously reported. [3],[5] i.e absence of `a' wave following atrial sys­tole in six out of 11 cases. Exception to this were three patients with severe pul­monary hypertension complicated by mo­derate to severe right heart failure and elevated right ventricular end diastolic pressure (RVEDP-13 mm Hg., 8 mm Hg. and 15 mm Hg. respectively) in whom `a' wave was present (5 mm., 3 mms. and 5 mms. respectively) despite pulmonary hypertension. As against this in one pa­tient with severe pulmonary hypertension and right ventricular failure (RVEDP­25 mm), `a' wave was absent. Broadly speaking therefore, Amax seems to lose its correlative value in pulmonary hyper­tension in the presence of raised RVEDP.

In pulmonary hypertension the inc - .eas­ed pulmonary artery pressure results in pulmonary valve opening in a relatively high portion of the right ventricular pres­sure curve where the pressure is rising rapidly. This probably explains the acce­lerated opening rate of the pulmonary valve observed in all our patients. Simi­lar finding have already been reported . [3]

It has been observed in this series that the diastolic position of the pulmonary valve i.e. 'ef' slope although useful in identifying pulmonary hypertension, does not help in evaluating its severity. Two of our patents showed a negative [5] 'ef' slope, six patients had flat [5] `ef' slope and the remaining three had normal [5] 'ef' slope though they had moderately severe pul­monary hyprtension. It is therefore ob­served that flat or negative 'ef' slope could be a good predictor of pulmonary hyper­tension. The same view has been shared by other investigators. [3],[5]

Mid-systolic closure and fluttering was observed by Weyman et al [5] in 22 out of 24 patients with pulmonary hypertension. We have observed this finding in only 3 out of 11 patients. The reason for this midsystolic phenomenon might be a de­crease of pulmonary blood flow in pul­monary hypertension which allows early closure of the leaflets. [5] Pulmonary artery dilatation which occurs in pulmonary hy­pertension permits the fully open leaflets to remain in the turbulant stream of blood and this may be the explanation for midsystolic fluttering observed in cases of pulmonary hypertension. [5]

The amplitude of valve opening move­ment (bc slope) was found to be least useful criterion in separating pulmonary hypertensive from a normotensive pa­tient. This view has also been shared by previous authors. [3]

The ratio of RPFP and RVET which reflects the right ventricular performance was not found to be increased by us, as reported previously. [2]

Pulmonary Stenonsis

This group with right ventricular out­flow obstruction is indeed limited, but all the echographs were studied in retros­pect after the correlates in surgery and angiography were obtained.

First patient with valvar and infun­dibular stenosis with right ventricular pressure of 250/0 mm Hg. and main pul­monary artery pressure of 50/10 mm Hg. had Amax of 7 mm. with no change in 'a' wave depth with respiration. Right atrial `a' wave was 9 mm Hg. Interest­ingly the valve had been wide open be­fore the onset of, ventricular systole. This phenomenon of presystolic opening of the pulmonary valve though commonly found in severe pulmonary stenosis is not specific for the same. Its presence depend upon the relative pressures existing across the pulmonary valve after atria contraction, and upon an increase in the right ventricular end-diastolic pressure in the presence of normal or low pulmonary artery pressure. Similar findings have been reported in rupture of the sinus of valsalva aneurysm into right atrium [6] and Loeffler's endocarditis with tricuspid in sufficiency. [4] Systolic fluttering of the pulmonary valve was observed in the same patient. This finding has been known to be associated with pure infun­dibular stenosis and said to differentiate it from isolated valvar stenosis; [7] it was absent in the patient with isolated infun­dibular stenosis in this series. The sign is less useful in combined valvar and in­fundibular stenosis when its occurrence is variable. Systolic fluttering of the pul­monary valve was also observed in this series (See [Figure 6] on page 218'B) in a case of large isolated subaortic membranous ventricular septal defect with left to right shunt and no gradient across the pul­monary valve. Two patients with ventri­cular septal defect, associated with in­fundibular stenosis and combined valvar infundibular stenosis had no echographic features suggestive of either valvar or infundibular pulmonary stenosis


1Gramiak, R., Nanda, N. C. and Shah, P. M.: Echocardiographic detection of the pulmonary valve. Radiology, 102: 153-158, 1972.
2Hirschfeld, S., Meyer, R., Schwartz, D. C., Korfhagen, J. and Kaplan, S.: The echocardiographic assessment of pulmon­ary artery pressure and pulmonary vas­cular resistance. Circulation, 52: 642-650, 1975.
3Nanda, N. C., Gramiak, R., Robinson, T. 1. and Shah, P. M.: Echocardiographic eva­luation of pulmonary hypertension. Cir­culation, 50: 575-581, 1974.
4Weyman, A. E.: Pulmonary valve echo motion in clinical practice. Amer. J. Med., 62: 843-855, 1977.
5Weyman, A. E., Dillon, J. C., Feigenbaum, H. and Chang, S.: Echocardiographic pattern of pulmonary valve motion with pulmonary hypertension. Circulation, 50: 905-910, 1974.
6Weyman, A. E., Dillon, J. C., Feigenbaum, H. and Chang, S.: Premature pulmonic valve opening following sinus of valsalva aneurysm rupture into the right atrium. Circulation, 51: 556-560, 1975.
7Weyman, A. E., Dillon, J. C., Feigenbaum, H. and Chang.. S.: Echocardiographic dif­ferentiation of infundibular from valvular pulmonic stenosis. Amer. J. Cardiol,, 36: 21-26, 1975.

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