MioAtlas
G2: Right-sided valves

Pulmonic regurgitation

Incompetence of the pulmonary valve resulting in pathological backflow of blood from the pulmonary trunk into the right ventricle during diastole.

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Definition

Incompetence of the pulmonary valve characterized by retrograde regurgitant flow of blood from the pulmonary trunk into the right ventricle during diastole, secondary to congenital causes (post-valvulotomy, repair of Tetralogy of Fallot), idiopathic annular dilation, or endocarditis, in the absence of severe pulmonary hypertension, conditioning progressive right ventricular volume overload [C4] [C5] [V3] [G23-03].

Severity criteria

  • Mild (L): Jet width at origin < 25 % of right ventricular outflow tract (RVOT); vena contracta (VC) not measurable or very narrow; Pressure half-time (PHT) > 100 ms; Slow Doppler deceleration slope; Regurgitant fraction (RF) < 20 % [V3] [G23-03].
  • Moderate (M): Jet width 25–50 % of RVOT; Intermediate VC; PHT 100–100 ms; RF 20–39 % [V3] [G23-03].
  • Severe (G): Jet width > 50 % of RVOT; Wide VC; Pressure half-time (PHT) < 100 ms; Steep diastolic deceleration slope with early termination of diastolic flow (AP-RV pressure equalization before end-diastole); Holodiastolic retrograde flow in pulmonary artery branches; Regurgitant fraction quantified by cardiac MRI ≥ 35–40 % (or RF ≥ 50 % by classical criteria) [V3] [C5] [G23-03] [C4].

Findings by layer

Hemodynamics

  • Rapid diastolic pressure equalization between pulmonary artery and right ventricle at end-diastole with minimal residual mean diastolic gradient (low mean gradient in mmHg) [V3] [G23-03].
  • Right ventricular volume overload with markedly increased RV end-diastolic volume [C5] [V3].

Rhythm

  • Normal sinus rhythm [C5].

ECG

  • Signs of right ventricular volume overload: Incomplete or complete right bundle branch block (incomplete right bundle branch block or complete right bundle branch block) with progressive widening of the QRS complex [E2] [C5].
  • Right axis deviation in the presence of advanced right ventricular dilation [E1].

Heart sounds and murmurs

  • Decrescendo diastolic murmur: Early to mid-diastolic murmur of soft quality and low/medium pitch, decrescendo, auscultated at the 2nd–3rd left intercostal space (pulmonic area and left sternal border), typically ending before S1 due to early cessation of the PA-RV diastolic gradient [G1-15] [V3]. (Semiologic note: In the absence of pulmonary hypertension, the murmur is not high-pitched or blowing like the Graham Steell murmur, but lower-pitched and briefer).
  • Inspiratory increase: Loudness of the diastolic murmur increases with inspiration due to increased venous return and filling in the right-sided circuit [G1-15] [B1].
  • Second heart sound (S2): Widely split S2, physiological or pathological secondary to conduction delay in the right bundle [G1-11].
  • Right-sided third heart sound (S3): Present at LLSB in severe right ventricular volume overload [G1-12].

Arterial pulse

  • Normal peripheral arterial pulse (does not exhibit the peripheral diastolic collapse typical of severe aortic regurgitation) [B4].

Jugular venous pulse

  • Generally normal in early stages; prominent 'v' wave if secondary functional tricuspid regurgitation develops due to right annular dilation [B3].

Maneuvers

  • Inspiration: Increases intensity of the pulmonary diastolic murmur (classic semiologic response of right-sided murmurs) [B1] [G1-15].
  • Valsalva maneuver: Attenuates the murmur during the forced expiratory strain phase with rapid post-strain recovery [B1].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Normal Sinus Rhythm

Also known as: Pulmonic regurgitation · Pulmonary regurgitation · Pulmonary valve insufficiency · Pulmonic insufficiency · PR

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C4] 2025 ACC/AHA/HRS/ISACHD/SCAI Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2025) . DOI: 10.1161/CIR.0000000000001402 PubMed: 41411375
  5. [C5] 2020 ESC Guidelines for the management of adult congenital heart disease . Eur Heart J (2020) . DOI: 10.1093/eurheartj/ehaa554 PubMed: 32860028
  6. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  7. [E2] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191095 PubMed: 19228822
  8. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  9. [G1-12] The Third Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250184
  10. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  11. [G23-03] European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease) . Eur J Echocardiogr (2010) . DOI: 10.1093/ejechocard/jeq030 PubMed: 20375260
  12. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623