Right ventricular outflow tract obstruction physical examination
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Right ventricular outflow tract obstruction Microchapters |
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Classification |
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Differentiating Right ventricular outflow tract obstruction from other Diseases |
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Diagnosis |
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Treatment |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
Pulmonic stenosis is an acynotic condition which may present with cyanosis when associated with interatrial right-to-left shunt. Patients are normally healthy but on auscultation an ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border.
Physical Examination
Appearance of the patient
- Patients appear healthy
- A small percentage of patients have Noonan's syndrome:
- Small stature, retarded, triangle-faced shape, webbed neck, ptosis, hypertelorism, low set ears, and pectus.
- Noonan syndrome is familial.
Neck
- If the lesion is severe (>75 mm Hg pressure gradient) then there is a giant "a wave" secondary to the reduced compliance of the right ventricule, otherwise JVP is normal.
Heart
Palpation
- Right ventricular heave or lift is present in moderate to severe pulmonary stenosis.
- A precordial thrill is present in case of severe obstruction at the left suprasternal notch and the left upper sternal border.
Auscultation
Heart Sounds
- In mild forms, the pulmonic component of the second heart sound is loud.
- In severe forms, the pulmonic component of the second heart sound may be missing.
- Fourth heart sound (S4) is heard at the left lower sternal border in presence of severe stenosis.
- Ejection click is often present and best heard at the left sternal border. Loudness of the click decreases with inspiration.
Murmurs
- There is a loud systolic ejection murmur loudest in the second left intercostal space which peaks in late systole.
- It radiates into axillae and back.
- Severe stenosis is clinical assessed by:
- long duration and late peaking of the ejection systolic murmur,
- short interval between the first heart sound (S1) and ejection click,
- increase in width between aortic (A2) and pulmonic component (P2) of the second heart sound (S2), and
- soft pulmonary component of second heart sound (P2)
- Other murmurs:
- Severe pulmonary stenosis can lead to tricuspid regurgitation which results in an holosystolic murmur best heard at the left lower sternal border.
- An associated pulmonary regurgitation will result in an early diastolic decrescendo murmur.
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