Pulmonary regurgitation

Overview

•Often asymptomatic - discovered incidentally on echo or during workup for pulmonary hypertension/post-cardiac surgery

•When symptomatic, features reflect right heart failure:

•Fatigue and exertional dyspnoea - reduced right-sided cardiac output

•Raised JVP - elevated right atrial filling pressure

•Peripheral oedema and ascites - venous congestion

•Pulsatile hepatomegaly - transmitted pulsations via IVC to liver (key distinguishing feature)

•Right ventricular heave - parasternal lift from RV dilatation

•Murmur: early diastolic, decrescendo, blowing, soft - loudest at left sternal border, 2nd intercostal space; increases on inspiration (augmented venous return accentuates all right-sided murmurs)

💡

Graham Steell murmur - soft, high-pitched, blowing, decrescendo early diastolic murmur at the left sternal border caused by PR in the context of pulmonary hypertension. Classically associated with mitral stenosis causing pulmonary hypertension; valve leaflets are structurally normal - dilated pulmonary artery stretches the annulus.

Investigations

🥇 First-line

•Transthoracic echocardiogram (TTE) - confirms PR, quantifies severity, assesses RV size and function, estimates pulmonary artery pressures

•ECG - RV hypertrophy (dominant R in V1, right axis deviation); P pulmonale if pulmonary hypertension present

•Chest X-ray - RV enlargement, dilated pulmonary arteries, underlying lung disease

•Gold standard (for intervention planning): Cardiac MRI - quantifies regurgitant fraction and RV volumes

Management

🥇 First-line

•Treat the underlying cause - manage pulmonary hypertension, optimise COPD, treat infective endocarditis with appropriate antibiotics

•Asymptomatic mild-to-moderate PR with preserved RV function - surveillance echocardiography only, no valve intervention

•Furosemide for symptomatic fluid overload - reduces preload and congestion

🥈 Second-line

•Pulmonary valve replacement (surgical or transcatheter) for severe symptomatic PR with RV dilatation or dysfunction - most important in post-tetralogy of Fallot repair patients

📌

In repaired tetralogy of Fallot, late severe PR is the dominant long-term complication and the leading indication for re-intervention (pulmonary valve replacement).

Cor pulmonale and right heart failure

•Right heart failure secondary to chronic lung disease (e.g. COPD) = cor pulmonale

•COPD → pulmonary hypertension → RV hypertrophy → RV failure → raised JVP, hepatomegaly, ankle oedema

•Pulsatile hepatomegaly distinguishes right heart failure from other causes of hepatomegaly (viral hepatitis, alcoholic liver disease, metastases, abscess - none are pulsatile)

🎯

A firm, smooth, tender, pulsatile liver = right heart failure until proven otherwise. The pulsatile quality is the key discriminating feature in the exam.