Right ventricular outflow tract obstruction (patient information)
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief:
Overview
The pulmonary artery is the main artery leaving the heart. When blood leaves the heart, it flows from the lower chamber (the left ventricle), through the pulmonic valve, into the pulmonary artery. In pulmonic stenosis, the pulmonic valve does not open fully. This restricts blood flow from the heart to lungs.
What are the symptoms of pulmonic stenosis?
You may have no symptoms at all until late in the course of the disease. The diagnosis may have been made when your healthcare provider heard a heart murmur and then performed additional tests.
Symptoms in adults:
- Breathlessness with activity.
- Chest pain, which resembles what is known as angina-type pain.
- The pain is crushing, squeezing, pressure or tightness in nature.
- The pain increases with exercise, relieved with rest.
- The patient feels pain under the chest bone, it may move to other areas.
- Fainting, weakness, or dizziness with activity.
- Sensation of feeling the heart beat (palpitations).
What causes aortic stenosis?
In the United States, pulmonic stenosis often results from calcium deposits on the pulmonic valve. These deposits occur naturally with age and have no relationship with the amount of calcium in the diet. Worldwide, aortic stenosis occurs most commonly in those who've had rheumatic fever, a condition that may develop after strep throat or scarlet fever. Valve problems do not develop for 5 - 10 years or longer after rheumatic fever occurs. Rheumatic fever is increasingly rare in the United States. pulmonic stenosis may be present from birth (congenital), or it may develop later in life (acquired). Children with pulmonic stenosis may have other congenital conditions. Radiation treatment to the chest, and some medications may cause pulmonic stenosis. pulmonic stenosis is not common. It occurs more often in men than in women. As the pulmonic valve becomes more narrow, the pressure increases inside the lower chamber of the heart (the right ventricle). This causes the right ventricle to become thicker, decreasing blood flow and can lead to chest pain.
Who is at highest risk?
pulmonic stenosis occurs more often in men than in women. The calcifications that cause most cases of pulmonic stenosis are more likely to occur in patients above the age of 50, who are overweight, who smoke, and who have diabetes, high blood pressure, and high cholesterol. These are the same risk factors for atherosclerosis of the coronary blood vessels.
Diagnosis
- Heart murmur: When listening to your heart, your health care provider may hear a new heart murmur associated with pulmonic stenosis. This murmur is not always there in pulmonic stenosis. If a new murmur is heard and your health care provider is concerned about pulmonic stenosis or another form of heart disease, further tests may be ordered. It is important to remember that not all heart murmurs mean you have a harmful heart condition.
- Blood pressure: You may have high blood pressure if you have mild pulmonic stenosis. In rare cases of severe pulmonic stenosis, your blood pressure may actually be low.
- Tests:
- Chest X-ray
- Electrocardiogram: Sensors on the chest measure electrical activity of the heart.
- Echocardiography: It is an ultrasound of the heart.
- Exercise stress testing: Your doctor monitors your electrocardiogram while you exercise.
- MRI of the heart: You lay in a magnet that takes pictures of your heart.
- Cardiac catheterization: A catheter is inserted into the arteries of your heart and pictures are taken.
When to seek urgent medical care?
Call your health care provider if you or your child have symptoms of pulmonic stenosis. For example, call if you or your child have increasing shortness of breath, chest pain or fainting. Also contact your doctor if you have been diagnosed with this condition and your symptoms get worse or new symptoms develop.
Treatment options
If there are no symptoms or symptoms are mild, you may only need to be monitored by a health care provider. Patients with pulmonic stenosis may be told not to play competitive sports, even if they don't have symptoms. If symptoms do occur, strenuous activity must be limited.
In adults, treatments include:
- Medication: Medications are used to treat symptoms of heart failure or abnormal heart rhythms (most commonly atrial fibrillation).
diuretics (water pills), nitrates, and beta-blockers. High blood pressure should also be treated.
- Lifestyle changes: Stop smoking and be treated for high cholesterol. See a cardiologist every 3 to 6 months.
- Surgery: Surgery to repair or replace the pulmonic valve is the preferred treatment for adults or children who develop symptoms. Even if symptoms are not very bad, the doctor may recommend surgery. People with no symptoms but worrisome results on diagnostic tests may also require surgery.
- Valvuloplasty: Some high-risk patients may be poor candidates for heart valve surgery. A less invasive procedure called balloon valvuloplasty may be done in adults or children instead. This is a procedure in which a balloon is placed into an artery in the groin, advanced to the heart, placed across the valve, and inflated. This may relieve the obstruction caused by the narrowed valve.
- Percutaneous pulmonic valvular replacement is a new less invasive procedure that does not require open heart surgery. In this procedure, a new replacement or prosthetic valve is implanted into the heart. The device is inserted through a small hole in the artery that runs to the leg. It is a relatively new procedure and is currently under study. It has the benefits of not requiring general anesthesia, causing less pain, less blood loss, and a lower risk of infection. There is also a faster recovery after PPVR than with traditional open heart surgery to replace the pulmonic valve.
In children, treatments include:
- Physically activity limits: Children with mild pulmonic stenosis may be able to participate in most activities and sports. As the illness progresses, sports such as golf and baseball may be permitted, but not more physically demanding activities.
- Surgery: Valvuloplasty is often the first-choice for surgery in children. Some children may require pulmonic valve repair or replacement.
What to expect (Outlook/Prognosis)?
People with mild pulmonic stenosis may do very well using a watchful waiting approach with their health care provider. They may be treated medically for some conditions associated with pulmonic stenosis, such as high blood pressure, and may have a normal life expectancy.
Those with more severe symptoms, such as chest pain or signs of heart failure like shortness of breath and leg swelling, generally do poorly without surgery. However, surgery does have the potential to cure a person's pulmonic stenosis. The success of surgery depends on a number of factors, including patient age, overall activity level, and presence of other medical conditions. As with any operation, aortic valve surgery has some risks, most of which occur during the first 1-2 days after surgery.These include an irregular heart rhythm and blood clots in the legs. There is also a chance that the new or repaired valve may stop working which might require another surgery.
Prevention
Treat strep throat promptly to prevent rheumatic fever, which can cause pulmonic stenosis.
Follow your health care provider's treatment recommendation for conditions that may cause valve disease. Notify you provider if there is a family history of congenital heart diseases.