Case - Pulmonary Valvular Stenosis

Parasternal long axis view

One may already appreciate that the RVOT is dilated and that the RV wall and septum are significantly hypertrophied.

In the posterior sweep, one may see the tricuspid regurgitant jet, and appreciate that there is subjective RV hypertrophy and right atrium dilatation.

Parasternal short axis view

In these views, one may appreciate that the pulmonary valve is doming. The valve is dysplastic. Although the annulus is of good size, there is critical pulmonary valvular stenosis. The opening is extremely narrowed. By colour, one may appreciate that there is turbulence. The flow originates before the valve and goes through the valve. There is a "red flame" representing the ductus arteriosus feeding the pulmonary artery.

The RV is suprasystemic, dilated and with hypertrophy. There is bowing of the setpum in systole (supra-systemic RV pressure due to the RVOT obstruction). There is flattening of septum in diastole (outlining some degree of RV diastolic dysfunction).

PDA view

Restrictive left to right PDA.

PDA gradient of 28 mmHg (left to right) with a restrictive pattern (before prostaglandins). This outlines that the systolic PA pressure is about 28 mmHg below the systolic systemic blood pressure.

PDA has increased in caliber upon initiating prostaglandins.

Apical view

The RV-focus view outlines that the RV is significantly dilated and hypertrophie. The right atrium is significantly dilated. This is secondary to the severe tricuspid regurgitant jet (seen with colour). This occurs in the context of the significant RVOT obstruction. The TRJ predicts a RV-RA gradient of 98 mmHg, outlinig that the RV is supra-systemic.

In this anterior sweep, one may appreciate that the RV is tri-partite. The pulmonary valve is seen: dysplastic, doming and with critical pulmonary stenosis. The main pulmonary artery seems dilated (subjectively).

Zoom on the pulmonary valve from the apical view.

Colour box outlines that there is turbulence (despite the high Nyquist - velocity filter) at 143 cm/s.

The subcostal views outline that the PFO is right to left.

Gradient through the pulmonary valve is estimated at 32-34 mmHg, depending on the angle of the CW-Doppler. The gradient may not fully outline the degree of RVOT obstruction in the context of: A) the high pulmonary vascular resistance (day 1 of life at echocardiography), B) the presence of the PDA with a competitive jet towards the valve, C) the limited flow through the critical pulmonary stenosis.

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