SUMMARY the Echogram of the Pulmonary Valve Was Recorded in 11 Normal Subjects and in 70 Patients with Various Underlying Disease

Echocardiogram of the Pulmonary Valve

Tsuguya SAKAMOTO, M.D., FACC, Mokuo MATSUHISA, M.D., Terumi HAYASHI, M.D., and Hirofumi ICHIYASU, M.D.

SUMMARY The echogram of the pulmonary valve was recorded in 11 normal subjects and in 70 patients with various underlying disease. On the routine examination, the detection of the pulmonary valve was about 20%, but the aimed study disclosed the valve more frequently. The technique was described in detail. The anterior wall of the pulmonary artery is located 1 to 2cm from the chest wall, and the posterior wall has wide and dense echoes. Ultrasound cardiotomography disclosed the lateral aspect of the left atrium behind the posterior wall. The pulmonary valve echo was generally weak and the left cusp was detected as a distinct echo, which moves posteriorly during systole. The echo was easily detected in cases with pulmonary hypertension, in which the anterior cusp was also depicted easily. The recording site was not so restricted in such cases. The pulmonary hypertension made the echo strong during both in systole and diastole, and gave the pattern of midsystolic semi-closure and diastolic plateau. Additional Indexing Words: Ultrasound cardiography Ultrasono-cardiotomography Phono- cardiography Pulmonary hypertension

EW studies of the pulmonary valve echogram have been published, pro- F bably because of the technical difficulty to detect the valve on routine echocardiography.1)-4) The present communication summarizes experience with pulmonary valve echogram in various conditions including 11 normal subjects, with particular reference to the method, echo pattern and some of the implications to the echocardiography.

MATERIALS AND METHODS

Eighty-one cases were selected to study the pulmonary valve echogram during past 14 months. All the cases had the echogram sufficiently enough to study the present subject. The age ranged from 7 to 66 years, averaged 31.1 years and the

From the Second Department of Internal Medicine, Faculty of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113. The preliminary report was presented at the 67th Kanto Regional Meeting of the Japanese Circu- lation Society in February 24, 1973. Received for publication March 8, 1974. 360 Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 361

Table I. Classification of 81 Cases

sex ratio was 40:41. The diagnosis of each case was finally made by routine graphic methods including cardiac catheterization and angiocardiography (Table I). Echocardiogram was recorded using SSD-33 (Aloka Co, Ltd) with an un- focused transducer of 2.25MHz, 1.0cm in diameter, having a repetition rate of 1,500impulse per second. In all cases,electrocardiogram and phonocardiogram were recorded simultaneously.The calibration marks on the oscilloscopewere set so that adjustment of the lines represented 0.2 or 0.5sec horizontally (speed of sweep was 50 or 20mm/sec), and 1.5 or 2.0cm of tissue depth vertically. In addition, ultrasono-cardiotomography5),6) using Aloka SSD-34 C was performed to confirm the pulmonary valve and to search the anatomical structure in the vicinity of the valve and the pulmonary artery. The recent cases were investigated using the strip-chart recorder, Aloka SSD- 90, in which the polygraphic recordings are made with a high paper speed.

RESULT 1. Detection of the pulmonary valve: Firstly, the aortic root echo was detected from the 3rd left interspace in the resting recumbent position. Then, the echo beam was gradually directed upward and laterally until the aortic wall and valve echoes disappeared and the echo of the pulmonary artery was obtained. In normal subjects and in patients with normal pulmonary artery pressure the direction of echo beam to detect the pulmonary artery and valve was so limited that the echo pattern was uniform and stable, once it was detected. In cases with elevated pulmonary artery pressure and/or the dilatation of the pulmonary artery , the recording site was dislocated from the sternal margin and showed wide distribu- tion, so that the pulmonary valve echo was sometimes obtainable even from JJap. Heart J. 362 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU uly, 1974 the 2nd or 4th interspace. To obtain the clear valve echo, the coarse gain should be increased, whereas the near gain should be depressed, and then the rejection control was adjusted adequately. 2. Identification of the pulmonary artery and the adjacent tissue : To identify the pulmonary artery, the M-mode scanning4) was useful. In Fig.1, M-mode scanning was performed with the tilting transducer at the the 3rd left interspace and on the line depicted on the chest X-ray. The pulmonary artery showed the nearest echo from the chest wall and was well separated from the echoes of aorta, mitral and tricuspid valves. Ultrasono-cardiotomogram (Fig.2) revealed the spatial relationship among left ventricle, outflow tract of left ventricle, left atrium, and right ventricle. The posterior aspect of pulmonary artery showed a strong and wide echo (about 1cm) due to the atrio-pulmonary sulcus, and the lateral cavity of the left atrium was depicted posteriorly. The anterior aspect was com- posed of the outflow of the right ventricle or, in some cases, the anterior wall of the pulmonary artery. However, it was difficult to separate the echo from that of the chest wall in many cases. 3. Identification of the pulmonary valve : Though the echo of the valve was usually weak in cases without pulmonary hypertension, it was identified by the opening movement during systole. Ultrasono-cardiotomography demonstrated that the anterior movement was due to the anterior cusp, whereas the posterior movement was ascribed to the left cusp. The overall detection rate of the sufficient pulmonary valve echo was 19.6% (81 out of 414 cases), but this figure was thought to be largely depending on the earnestness of the examiner. In many instances, the detection of the valve was not attempted in the past. Recently, this figure is increasing steadily (over 50%). 4. Echo pattern of the pulmonary valve: In normal subjects, the pulmonary valve echo showed the quick opening motion during systole, which was demonstrated by the posterior movement of the echo of the left cusp (Fig.3). During systole, the echo moved anteriorly. The anterior cusp echo was usually undetected in cases without pulmonary hypertension. During end-systole, the echo moved to the chest wall and the closing point of the valve was nearer to the transducer than the opening point. Then, the single echo slightly moved anteriorly and thereafter gradually moved posteriorly during diastole according to the filling of the right ventricle. During atrial systole, a small posterior movement was observed in all cases with sinus rhythm, and it was prominent in a case of valvular pulmonary stenosis. Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 363

Fig.1. M-mode scan in a case of post-operative endocardial cushion defect, 24-year-old female. The tilting transducer is placed at the 3rd left intercostal space and directed from pulmonary valve (PV) to aortic root (AR) (top figure), and from PV to mitral valve (MV) and tricuspid valve (TV) (bottom figure). The scanning direction is indicated on the chest X-ray film. Both anterior and left cusps of the pulmonary valve are depicted. The bottom figure was obtained 3 months earlier than the top figure, and had abnormal septal motion and tricuspid valve fluttering probably due to the pulmonary regurgitation , which still remained at that time. Jap. Heart J. 364 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU July, 1974

Fig.2. Ultrasono-cardiotomogram and echocardiogram in a case of Eisenmenger complex, 32-year-old female. Ultrasono-cardiotomogram (top left) was obtained with the 10cm focused transducer placed over the 3rd intercostal space. The sector motion of the transducer is schematically delineated on the chest X-ray film. Line A and B correspond to the direction of the echo beam, by which the echogram A and B are obtained by the same transducer when the sector motion is stopped. Large VSD is seen on the tomogram. P and PV: pulmonary valve, RV: right ventricle, M and MV: mitral valve, LA: left atrium. Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 365

Fig.3. Pulmonary valve echo in a healthy girl (15-year-old) (top) and in a case of essential hypertension (50-year-old male). Jap. Heart J. J 366 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU uly, 1974 5. Effect of respiration and arrhythmias : The echo pattern of the pulmonary valve showed the variation during respiration. The diastolic posterior movement was more rapid during inspiration. The posterior movement during atrial systole was more marked during inspiration and sometimes merged with the systolic posterior movement. Beat-to-beat variation was observed in cases with atrial fibrillation. Right-sided pulsus alternans, which was not anticipated before the recording of indirect pulmonary artery pulse tracing, was clearly demonstrated by the alteration of the pulmonary valve echo. With a strong beat, the period of valve opening was longer and the diastolic posterior movement was more rapid (Fig.4). 6. Effect of pulmonary hypertension: Pulmonary hypertension characterized the echo in the following man- ner.

Fig.4. Pulmonary valve echo in a case of pulsus alternans, 9-year-old girl. Note the alternating pattern of the pulmonary valve echo. Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 367

Fig.5. Pulmonary valve echo in cases of mildly and moderately elevated pulmonary artery pressure. Top: Lutembacher syndrome, 36-year-old female . PA pressure=37/14 mm Hg, left-to-right shunt ratio=75.2% . Bottom: mitral stenosis and tricuspid insufficiency, 24-year-old male. PA pressure=61/28mm Hg . Systolic abnormal movement (W-shaped echo) is also suggestive . Jap. Heart J J 368 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU uly, 1974

Fig.6. Abnormal systolic echo of the pulmonary valve in cases of extreme pulmonary hypertension. Top: Eisenmenger complex, 23-year-old male. PA pressure=120/63 mm Hg, left-to-right shunt=50.9%, right-to-left shunt=23.4%. Bottom: Eisenmenger syndrome, 46-year-old male. Typical W-shaped echo of the left cusp is observed during systole. The anterior cusp is also in- scribed. Vol.15 ECHOCARDIOGRAM OF PULMONARY VALVE 369 No.4 a. With increased pulmonary artery pressure, the echo became stronger and easily detectable during both systole and diastole (Fig.5). b. The diameter of the pulmonary artery increased up to 4.5cm, and the excursion of the cusp also increased. c. Particular echo was observed in almost all cases with moderate or severe pulmonary hypertension, which was characterized by the W-shaped echo of the left cusp (and occasionally M-shaped echo of the anterior cusp) during systole (Fig.6). The point of mid-systolic echo peak was variable from case to case, depending on the duration of the concomitant systolic murmur. d. In addition, the diastolic as well as the atriosystolic posterior move- ments were lost in cases with severe pulmonary hypertension, so that the diastolic pattern became similar to that of the anterior mitral cusp echo in mitral stenosis (cf. Fig.2, 6, 7). Such a pattern was observed in 8 out of 9 cases, in which there was severe pulmonary hypertension identical to the systemic level. An exceptional case had severe tachycardia, so that the echo pattern during diastole was not enough to evaluate. On the other hand, no cases of normal pulmonary artery pressure level showed the diastolic plateau pattern.

Fig.7. Pulmonary valve echo during forced respiration . Eisenmenger complex, 23-year-old pregnant (last month). Note the fairly stable recording even during forced respiration . W- shaped systolic echo and diastolic plateau are typical . Jap. Heart J. 370 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU July, 1974 e. Finally, the echo pattern above-mentioned was barely influenced by respiration, so that fairly constant echo was obtained without holding the breath (Fig.7).

DISCUSSI The detection of the pulmonary valve echo has probably been attempted by many investigators without satisfactory success. In 1968, Nimura et al1) demonstrated the aimed recording of the pulmonary valve echo with the identification by ultrasono-cardiotomography. Later, Gramiak et al2) reported the technique for the detection and suggested the possible clinical implication of the pulmonary valve echo. Ingeniously, they contributed to the identification of the pulmonary echo by the inection of indocyanine green. The pattern of normal subjects and of some pathological conditions was also described, and the clinical application in some cases of congenital heart disease was recently reported by them7) and also by Feigenbaum and his associates.8) 1. Abnormal systolic movement of the pulmonary valve: The abnormal W-shaped systolic movement of the pulmonary valve seems to be worthy to discuss. Gramiak et al1) have already shown a part of this pattern, but no comment was made. Feigenbaum4) demonstrated 2 cases of pulmonary valve echo in his book, in which the W-shaped pattern was clearly displayed. Speculatively, he attributed this pattern to the "two phases of right ventricular ejection", and thought that this characteristic to the pulmonary valve echo in general. Apparently, however, Feigenbaum's cases surely had pulmonary hypertension, which gives the W-shaped echo during systole. We have never seen the definite mid-systolic peak of echo in cases without pulmonary hypertension. In this respect, our subsequent study will offer the conclusion that the peak of mid-systolic echo is actually the end- point of the effective right ventricular ejection.9) 2. Diastolic plateau pattern of the pulmonary valve echo: The diastolic plateau pattern of the pulmonary valve echo in cases with severe pulmonary hypertension was attributed to the high diastolic pressure of the pulmonary artery.1) Large pulmonary artery-right ventricular diastolic pressure gradient may eliminate the effect of pressure change due to the diastolic and atrio-systolic right ventricular inflow. 3. Clinical significance of the detection of pulmonary valve echo: Though the clinical usefulness of the pulmonary valve echo has not been established yet, certain implications are undoubtedly present. As described above, the degree of pulmonary hypertension may be objectively assessed by the pulmonary valve echo. An abnormal systolic move- Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 371

Fig.8. The follow-up observation of the pulmonary valve echo in a

case of acute myocardial infarction. 59-year-old male . Note the change of echo pattern in the course of illness . Details: see text. Jap. Heart J. J 372 SAKAMOTO, MATSUHISA, HAYASHI, AND ICHIYASU uly, 1974 ment of the cusps (W-shaped and M-shaped echoes), the diastolic plateau pattern, increased diameter of the pulmonary artery and the large excursion of the cusps, strong echo beam, and stable echo pattern, all are suggestive of pulmonary hypertension. The absence of all the features excludes the pres- ence of pulmonary hypertension even of mild degree. The feasibility of the recording of the echo in the same patient may also deserve to the evaluation of the clinical course in terms of the height of pulmonary artery pressure. Fig.8 demonstrates such a case of acute myocardial infarction, in which the acutely developed pulmonary hypertension and the subsequent convalescence (lowered pressure) were objectively monitored on the pulmonary valve echo. With the development of acute pulmonary edema, the diastolic plateau pattern was observed at the time of elevation of ST segment, and this was effaced at the stage of inverted T wave. However, the diameter of the pulmonary artery remained normal and the W-shaped motion

Fig.9. Abnormally situated semilunar valves detected by echocardiography. Eisenmenger syndrome, 46-year-old male. Horizontally directed echo beam from the 3rd left intercostal space depicted both semilunar valves simultaneously. PV: pulmonary valve, AV: aortic valve. Vol.15 No.4 ECHOCARDIOGRAM OF PULMONARY VALVE 373 was not observed, suggesting that the hypertension developed was not severe. The similar experience was always observed in the operated cases with various degree of pulmonary hypertension due to either congenital or acquired heart disease. Another usefulness of the pulmonary valve detection by echocardiography is the displacement of the semilunar valves in cases of transposition complex.3), 7),8) In this respect, the outstanding reports have already been published, and we have no additional data to be added. Fig.9 demonstrates the semilunar valves situated side by side, suggesting the same level of both valves. Although this case has no final diagnosis (tentative diagnosis is Eisenmenger syndrome of undetermined cause), the abnormally situated great vessels are clearly illustrated by this echogram.

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