These lesions shall be covered in less depth due to their decreased frequency of presentation in the MRCP PACES exam to left sided valvular lesions.
Right sided lesions are louder during inspiration. However, remember that during inspiration that the lungs are expanding and as such there is a larger distance between the stethoscope and the heart during inspiration. This means that the heart sounds may not always get louder with inspiration but that if they do it is a clear sign of a right sided valvular lesion.
- Congenital often from maternal rubella infection (commonest),
- Rheumatic fever (usually occurs along with other valvular lesions)
- Carcinoid syndrome (rarely occurs in carcinoid syndrome)
- Ejection systolic murmur louder during inspiration best heard in the pulmonary region.
- Soft or delayed P2
- Palpable pulmonary thrill and/or palpable pulmonary ejection click.
Severe signs: RV heave, prominent a wave in JVP (due to RV hypertrophy)
Note: Remember that pulmonary stenosis is one part of the tetralogy of fallot, and to look for the other signs of this tetralogy.
- Pulmonary HTN: primary and secondary (with secondary being the commonest cause)
- Post repair of Tetralogy of Fallot (ie. if pulmonary valvotomy done)
- Congenital lack of pulmonary valve
- Marfans syndrome (rare)
- As for all other right sided valves: IE, carcinoid or rheumatic valvular disease
- Loud P2 or absent P2 (if valve not present in repair of tetralogy of fallot or congenital)
- Signs of RVF: Peripheral oedema and raised JVP
- JVP: Accented A wave (but may not be visible if functional TR also occurs due to large CV waves from this!)
- Early diastolic murmur loudest during inspiration at the upper left sternal edge
Don’t forget that this could be a Graham-steele murmur. A PR murmur secondary to pulmonary hypertension, often from mitral stenosis so listen for the mid-diastolic murmur of MS after the PR murmur.
- Carcinoid syndrome
- Congenital partial tricuspid atresia
- Rheumatic fever (rare)
- Mid diastolic murmur loudest during inspiration
- Signs of raised backward pressure: Raised JVP, hepatomegaly & peripheral oedema.
Acute: Tricuspid endocarditis, trauma
Chronic: Pulmonary HTN, IE (look for signs of IV drug abuse), Rheumatic fever, carcinoid syndrome, Ebsteins anomaly.
- JVP: Giant CV waves
- Pansystolic murmur loudest on inspiration and at the lower left sternal edge.
- Pulsatile hepatomegaly
- Parasternal heave
Conservative with diuretics to treat symptoms of RVF unless symptoms uncontrollable or patient suffering from low cardiac output (angina or syncope) in which valvular repair or replacement should be considered.
Written by Dr Thomas Craven
Resources used to write this document are listed in the references section of this webpage