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Pulmonary regurgitation: causes, symptoms, diagnosis, treatment
Medical expert of the article
Last reviewed: 07.07.2025
Pulmonary regurgitation is an insufficiency of the pulmonary valve, causing blood to flow from the pulmonary artery into the right ventricle during diastole. The most common cause is pulmonary arterial hypertension. Pulmonary regurgitation is usually asymptomatic. Its sign is a decreasing diastolic murmur. The diagnosis is made by echocardiography. Usually, no specific treatment is required, except for treatment of the conditions causing pulmonary arterial hypertension.
Secondary pulmonary arterial hypertension is the most common cause of pulmonary regurgitation. Less common causes include infective endocarditis, surgical treatment of tetralogy of Fallot, idiopathic pulmonary artery dilation, and congenital valve abnormalities. Carcinoid syndrome, rheumatic fever, syphilis, and catheter trauma are rare causes. Severe pulmonary regurgitation is rare and most often results from an isolated congenital defect involving dilation of the pulmonary artery and pulmonary valve annulus.
Pulmonary regurgitation may contribute to the development of right ventricular hypertrophy and ultimately right ventricular dysfunction-induced heart failure (HF), but in most cases the role of pulmonary arterial hypertension in the development of this complication is much more significant. Rarely, acute heart failure caused by right ventricular dysfunction develops in endocarditis leading to acute pulmonary regurgitation.
Symptoms of pulmonary regurgitation
Pulmonary regurgitation is usually asymptomatic. Some patients develop symptoms of heart failure caused by right ventricular dysfunction.
Palpable signs reflect pulmonary arterial hypertension and right ventricular hypertrophy. They include a palpable pulmonary component (P) of the second heart sound (S 2) at the upper left sternal border and a pronounced right ventricular pulsation, which is increased in amplitude, at the left sternal border at the middle and lower levels.
On auscultation, the first heart sound (S1)normal. S1 may be split or single. If it is split, the P may be loud, heard immediately after the aortic component of S (A due to pulmonary arterial hypertension, and P may be delayed due to increased right ventricular stroke volume. S may be single due to rapid pulmonary valve closure coinciding with fused A and P components, or (occasionally) due to congenital absence of the pulmonary valve. A right ventricular third heart sound (S3), fourth heart sound (S4), or both may be heard in heart failure due to right ventricular dysfunction or hypertrophy. These sounds can be distinguished from the left ventricular heart sounds because they are heard on the left parasternal in the fourth intercostal space and increase in intensity with inspiration.
The murmur of pulmonary regurgitation due to pulmonary arterial hypertension is a high-pitched early diastolic decrescendo that begins on P, continues to S, and radiates to the middle of the right sternal border (Graham Still murmur). It is heard best at the left upper sternal border through a stethoscope with the diaphragm when the patient holds the breath on expiration and sits upright. The murmur of pulmonary regurgitation without pulmonary arterial hypertension is shorter, lower-pitched (rougher), and begins after P. Both murmurs may resemble the murmur of aortic regurgitation, but they can be distinguished during inspiration (which increases the murmur of pulmonary regurgitation) and the Valsalva maneuver. In the latter case, the murmur of pulmonary regurgitation immediately becomes loud (due to an immediate increase in venous inflow to the right chambers of the heart), and the murmur of AR increases in intensity after 4-5 heartbeats. In addition, the soft murmur of pulmonary regurgitation may sometimes become even softer with inspiration, since this murmur is usually heard best in the second left intercostal space, where inspiration moves the stethoscope away from the heart.
Diagnosis of pulmonary regurgitation
Pulmonary regurgitation is usually discovered incidentally during a physical examination or Doppler echocardiography performed for other reasons. An ECG and chest x-ray are ordered. Both may show evidence of right ventricular hypertrophy. Chest x-rays usually reveal conditions underlying pulmonary arterial hypertension.
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Treatment of pulmonary regurgitation
Treatment involves treating the condition causing pulmonary regurgitation. Pulmonary valve replacement is the treatment of choice for heart failure due to right ventricular dysfunction, but the results and risks are unclear because replacement is rarely needed.