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Lung failure

The pulmonary valve incompetence is relatively common, particularly the physiological, which has become more evident since the introduction of Doppler techniques as conventional diagnostic tool in cardiology.

Etiology

The differentiation between primary or secondary valvular dysfunction is very important in the evaluation of tricuspid or pulmonary valve. In the adult, valvular disease of the right cavities, especially regurgitation is commonly a result of pulmonary hypertension secondary to heart disease left cavities, primary lung disease or pulmonary vascular disease, the toxic oil syndrome in Spain, has been the source of pulmonary hypertension and pulmonary insufficiency (PI).

The most common cause of IP is the expansion valve ring secondary to pulmonary hypertension of any etiology. Unlike pulmonary stenosis, the IP is rarely congenital in origin and can occur in idiopathic dilated pulmonary artery. It can also be caused by a connective, such as Marfan syndrome. Infective endocarditis can cause acute IP, especially in people addicted to intravenous drugs and is the second most prevalent after pulmonary hypertension. The iatrogenic due to surgical repair of the EP or balloon pulmonary valvuloplasty is another possible etiology, appearing in slight degree in 90% of the percutaneous technique 15. It is also a common finding after correction of tetralogy of Fallot. Often, the IP is a casual light in Doppler echocardiography. Other less common causes relate to rheumatic involvement, tuberculosis, chest trauma and carcinoid syndrome ^{4 , 19,} 20 , although less frequently than in PD (Table 5).

Pathophysiology

The difficulty for the normal closure of the pulmonary sigmoid ventricular diastole involves the backflow of blood volume pair you ejected into the pulmonary artery with subsequent volume overload of the right ventricle. Is well tolerated for a long time, unless it is complicated by pulmonary hypertension.

idiopathic dilatation of the pulmonary artery is a clinical condition that causes pulmonary regurgitation, with the following characteristics: marked dilatation of the pulmonary artery trunk and the pulmonary annulus, with a right ventricle and normal pulmonary valve obstruction and a gradient was not significant. This expansion may result from an abnormality of connective tissue. Hemodynamically there is a pressure gradient in pulmonary valve and a mild degree discrete elevated heart rate ^{7 ,} 21.

Clinic

Most patients with mild degrees experience a benign clinical course. When hypertension occurs pulmonary clinic accompanied by right ventricular systolic dysfunction, may appear syncope, fatigue or dyspnea.

IP Patients with infective endocarditis secondary to septic pulmonary embolism may occur, pulmonary hypertension and severe right ventricular dysfunction. However, the predominant symptoms for the disease that triggers pulmonary hypertension (most common cause). When the IP accompanies carcinoid syndrome spells are observed facial flushing, diarrhea and wheezing among other symptoms 22.

Exploration physical

On palpation can reveal a hyperdynamic right ventricle in left parasternal area, pulmonary artery systolic pulsations can cause prominent in the 2 nd intercostal space left and can be felt both systolic and diastolic thrills.

A cardiac auscultation and pulmonary hypertension is accentuated second heart sound, the pulmonary component. May be split wide of the second sound due to the prolongation of right ventricular ejection imposed by the increase in stroke volume. A systolic ejection click, nonvalvular due to the sudden expansion of the pulmonary artery for right ventricular stroke volume increased, preceding a mid-systolic murmur, second stage, in the 2 nd intercostal space. A third and fourth noise that increases with inspiration, right origin, are heard often at the 4 th left intercostal space. In the absence of pulmonary hypertension the diastolic regurgitant murmur is serious tone, with its epicenter in the third and fourth left intercostal space price. Ogy diamond morphology is brief, increases with inspiration and inhalation of amyl nitrite 21.

When systolic pressure pulmonary artery exceeds 60 mmHg, the pulmonary annulus dilatation causes a regurgitant jet speed as evidenced by auscultation in the left parasternal border, a diastolic murmur of acute tone, in decrescendo, beginning after the pulmonary component of second sound and that is the breath of Graham Stell called the IP, which increases with inspiration and decreases during the pressure of the Valsalva maneuver. This resembles the murmur of aortic regurgitation, but is accompanied by severe pulmonary hypertension symptomatology. Unlike the aortic valve rarely stenotic and regurgitant lesions coexist in the pulmonary valve due to rheumatic etiology of the unusual and low pulmonary artery pressure in relation to the aorta. Carcinoid syndrome is an exception to this, as it is very common in lung involvement are given both types of lesions (Table 6).

In idiopathic dilated pulmonary artery can find the following auscultatory findings: pulmonary ejection click, systolic ejection murmur at pulmonary focus area, as well as a wide splitting of second sound.

Electrocardiogram

In the IP in the absence of pulmonary hypertension can be seen in the electrocardiogram (ECG) pattern of right ventricular diastolic overload, rSr morphology 'or rsR' in right precordial leads. Regurgitation secondary to pulmonary hypertension shows a classic pattern of right ventricular hypertrophy. Likewise, alterations can be observed auriculograma for the underlying disease.

chest radiograph

Both the pulmonary artery and right ventricle appears enlarged in significant pulmonary insufficiency, but are totally nonspecific findings.

Echocardiography

The IP is the most common physiological regurgitation, ie without structural heart disease. In different series have described their presence by pulsed Doppler, continuous or color, in 60% to 100% of healthy subjects ^{23, 24} .

are common in advanced IP right ventricular dilatation and hypertrophy of the cavity if accompanied by pulmonary hypertension. Abnormal movement or paradoxical interventricular septum is characteristic of situations of volume overload of the right ventricle. In M, the pulmonary valve movement suggests the cause of regurgitation, so the absence of "a" wave and systolic notch in the posterior leaflet should suggest pulmonary hypertension. It is also possible to see the image of flapping or flutter the tricuspid valve. Both M-mode or two-dimensional echocardiography can observe the presence of vegetations in cases of endocarditis as a cause of lung failure. The pulsed Doppler is a very precise technique for the diagnosis of pulmonary insufficiency of any etiology, shows reversed flow in the artery lung ^{3 ,} 25. The color Doppler shows abnormal flow, regurgitant, which back in the outflow tract of right ventricle (Fig. 3).

Fig. 3. Color Doppler pulmonary insufficiency. Ao: aorta; AD: right atrium; IP: pulmonary insufficiency; AP: pulmonary artery.

The diagnosis of pulmonary regurgitation is often made by echocardiography, so it is recommended periodically repeat this technique in patients at risk to manifest, such as pulmonary stenosis corrected (either by surgery as mine valvuloto percutaneous) or corrected Fallot 12.

The echocardiogram is the main diagnosis of idiopathic dilated pulmonary artery. Some authors proposed for diagnostic confirmation of these two parameters:

1. Relationship of pulmonary artery bifurcation / aortic diameter of 2 cm behind the aortic valve equal to or greater than 1.4.

2. Value pulmonary artery / aortic diameter equal to or greater than 1.5 26 .

Cardiac Catheterization

is of little use in the diagnosis of IP. It is much more sensitive in diagnosis echocardiography, as this regurgitation is not easily demonstrated by angiography. However, it may be useful for calculating pulmonary vascular resistance in patients with pulmonary hypertension.

Natural History

Most patients with mild IP has a benign clinical course. By contrast, the moderate to severe shows an evolution towards chronic volume overload right ventricle with ventricular dilatation and systolic dysfunction. The evolution of cardiac lesions in the patient with carcinoid syndrome is very fast, leading to right heart failure, but death occurs in the systemic disease, rarely by the pulmonary valve 5.

Treatment

no specific therapy is usually required in the treatment of lung failure. It is essential to identify and address the specific etiology of regurgitation and selectively treat the disorder, either endocarditis, pulmonary hypertension or carcinoid syndrome. Conventional medical treatment with digitalis and diuretics are used in case of right heart failure.

Surgical treatment is reserved for severe regurgitation with evidence of progressive dilatation of the ventricular cavity or to the onset of right ventricular systolic dysfunction. A small number of patients operated for tetralogy of Fallot and residual IP importantly, is the most common indication for surgery in pulmonary regurgitation. In these cases it is preferable to the use of bioprosthesis by the lower risk of thrombosis. However, the outcome of valve replacement has not yet been validated in a sufficient evolutionary control. Some cases with pulmonary valve endocarditis may require valvulectomía.

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