Pulmonic Stenosis

Question 1

Peak-to-peak pulmonic gradient is obtained upon ________________.

Answer 1

PA to RV pullback

Question 2

A peak-to-peak gradient of ______________ in symptomatic patients and ______________ in asymptomatic patients is an indication for repair (percutaneous repair if possible).

Answer 2

> 30 mm Hg
40 mm Hg

In echo
The severity of the lesion is defined by the echocardiography estimated peak instantaneous gradient, with mild stenosis less than or equal to 36 mm Hg (3 msec), moderate as 36 to 64 mm Hg (3 to 4 msec), and severe as greater than 64 mm Hg (4 msec).

Question 3

Pulmonic stenosis leads to ______________ but not to __________________

Answer 3

RV hypertrophy

NOT RV dilatation and Failure

Question 4

Hemodynamics of PS

Answer 4

RA pressure
-Large A wave
-Normal V wave

The RV maintains its function for years even when the RV pressure is in the systemic range; thus, one should look for an associated “volume” lesion such as ASD, TR, or pulmonic regurgitation in case of RV failure. Usually in PS, RV does not fail until later in life or in case of atrial arrhythmias (fifth decade).

Question 5

Following percutaneous valvuloplasty, the reduction in RV afterload may cause a ________________ across the hypertrophied RVOT and a residual gradient that is actually an intraventricular gradient.

Answer 5

Dynamic obstruction

The RVOT obstruction may be severe (“suicide RV”) and is initially treated with fluids, b-blockers, and calcium channel blockers. 16 This gradient resolves gradually.

Question 6

Catheter-based balloon valvotomy is recommended for patients with ____________________ and with peripheral PS (often with stent implantation).

Answer 6

Catheter-based balloon valvotomy is recommended for patients with non-dysplastic valvular PS and with peripheral PS (often with stent implantation)

Surgery is recommended for patients with sub-infundibular or infundibular PS and hypoplastic pulmonary annulus, with dysplastic pulmonary valves, and for patients with associated lesions which need a surgical approach, such as severe pulmonary regurgitation (PR) or severe TR. Peripheral PS can rarely be addressed with surgery.

Question 7

Class 1 indications for intervention in RVOT

Answer 7

In valvular PS, balloon valvuloplasty is the intervention of choice, if anatomically suitable.

Provided that no valve replacement is required, RVOTO intervention at any level is recommended regardless of symptoms when the stenosis is severe (Doppler peak gradient is >64 mmHgc ).

Class IIA
Peripheral PS, regardless of symptoms, should be considered for catheter interventional treatment if >50% diameter narrowing, and RVSP >50 mmHg, and/or related reduced lung perfusion is present.

Question 8

Review Braun on transcatheter therapies in PS