A 72-year-old woman presented to the hospital with lower extremity swelling for the previous few months. During her hospitalization, cardiac auscultation revealed a loud systolic murmur in the upper sternal borders. No diastolic murmur was appreciated. The patient reported being told she had a murmur for many years but that it was a benign murmur. She reported being relatively sedentary and did not report any increasing shortness of breath. As part of her workup, she underwent a transthoracic echocardiogram and subsequent cardiac magnetic resonance imaging (MRI).
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Based on the above information, which of the following is true?
Show Answer
The correct answer is: C. Pulmonary artery systolic pressure cannot be estimated from the above information.
This patient has a bicuspid pulmonic valve that was discovered on the MRI during her workup (Image 3, arrow), thus answer B is incorrect. Her pulmonic valve peak gradient is 81 mm Hg, consistent with severe pulmonary stenosis (Image 1).1 There is significant flow acceleration in her right ventricular outflow tract, consistent with severe pulmonic stenosis (Video 2). She also has marked dilation of her pulmonary artery with a main pulmonary artery measuring 7.5 cm, thus answer A is also incorrect (Image 4; Videos 1-3). Pulmonary artery systolic pressure is estimated by the peak pressure of the tricuspid regurgitant jet + RAP in the absence of pulmonic stenosis: 4 [tricuspid regurgitant jet velocity]2 + RAP.2 In the presence of pulmonic stenosis, pulmonary artery systolic pressure can still be estimated with the formula 4 [tricuspid regurgitant jet velocity]2 – peak pulmonic gradient + RAP. In this case, we have a tricuspid regurgitant jet peak gradient of 53 mm Hg (Image 2) and a peak pulmonic gradient of 81 mm Hg, which would result in a negative number. Thus, the tricuspid regurgitant jet was not accurately assessed on the study and pulmonary artery systolic pressure cannot be estimated. This makes answers D and E incorrect.
References
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2438-88.
Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685-713.
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