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Echocardiographic evaluation of the pulmonic valve and pulmonary artery

Nelson B Schiller, MD, FACC, FRCP, FASE
Bryan Ristow, MD, FACC, FASE, FACP
Xiushui Ren, MD
Section Editors
Warren J Manning, MD
William H Gaasch, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Echocardiographic imaging of the pulmonic valve and Doppler measurement of transpulmonary flow are potent tools in the clinical evaluation of disorders of the pulmonic valve and pulmonary arteries.  

The majority of clinically important lesions at the level of the valve, both stenotic and regurgitant, are associated with congenital heart disease. Rarely, acquired lesions, including endocarditis, rheumatic heart disease, and carcinoid heart disease, involve the pulmonic valve. Identification and characterization of these pathologies requires thorough echocardiographic interrogation and consideration of clinical context. Finally, evaluation of flow through the pulmonic valve and right ventricular outflow tract (RVOT) are essential elements for evaluating hemodynamics. Careful measurements can yield significant information regarding flow, pressure and resistance in the pulmonary circulatory bed.


Basic transthoracic views — Interrogation of the pulmonic valve by transthoracic echocardiography (TTE) begins with the parasternal short axis at the level of the aortic valve, where pulmonic valve anatomy can be examined for thickening, doming, or vegetation. Color flow Doppler is placed over the RVOT to detect flow acceleration or regurgitation. Then, using both continuous wave and pulse wave Doppler at the level of the pulmonary valve, velocities across the pulmonary valve in systole and diastole and peak velocities around the RVOT can be measured (figure 1 and image 1 and image 2). Several cycles of these views should be recorded to account for small variations in velocities during the respiratory cycle. M-mode through the pulmonary valve can also be obtained in this view. Tilting the probe in a slight cranial direction gives a clearer view of both the pulmonic valve and the proximal pulmonary artery (image 3). Color Doppler demonstrates flows proximal and distal to the valve and pulsed and continuous wave Doppler records the waveforms from that flow. The valve and artery may also be viewed from an orthogonal plane to assure complete interrogation of the structures and the most axial flow signals. Although the apical and subcostal views can be useful in imaging the right ventricle as it relates to the pulmonic valve and arteries (and occasionally allows for visualization of the pulmonic valve), it is often difficult to adequately image the pulmonary arterial system in these views. For further imaging of the branch pulmonary arteries, the suprasternal notch view with visualization of the aortic arch may be used (image 4).

Three-dimensional transthoracic views — If there is excellent visualization of the pulmonic valve in two dimensions, a three-dimensional reconstruction may be helpful in further defining valvular and proximal arterial anatomy. This may be especially useful when considering interventions on prosthetic valves [1].

Transesophageal echocardiography — The pulmonic valve can be imaged from several views [2]. First, it can be obtained by turning the probe counterclockwise from the mid-to-high esophageal ascending aorta long-axis view (approximately 110 to 130°). At this position, the main pulmonary artery is seen with the pulmonic valve in the far field. Spectral Doppler interrogations can be performed here. At the mid-to-high esophageal ascending aortic short-axis view (approximately 40 to 60°), both the RV inflow and outflow (including the pulmonic valve) can be visualized. Here, two of the pulmonic leaflets can be seen. In the presence of calcific aortic stenosis or aortic prosthesis, acoustic noise can limit visualization of the pulmonic valve, which is immediately anterior to the aortic valve.

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Literature review current through: Nov 2017. | This topic last updated: Jun 27, 2016.
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  1. Ahmed MI, Escañuela MG, Crosland WA, et al. Utility of live/real time three-dimensional transesophageal echocardiography in the assessment and percutaneous intervention of bioprosthetic pulmonary valve stenosis. Echocardiography 2014; 31:531.
  2. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013; 26:921.
  3. Awad SM, Masood SA, Gonzalez I, et al. The use of intracardiac echocardiography during percutaneous pulmonary valve replacement. Pediatr Cardiol 2015; 36:76.
  4. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr 2009; 22:1.
  5. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  6. Shively BK. Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve. Cardiol Clin 2000; 18:711.
  7. Bhattacharyya S, Toumpanakis C, Burke M, et al. Features of carcinoid heart disease identified by 2- and 3-dimensional echocardiography and cardiac MRI. Circ Cardiovasc Imaging 2010; 3:103.
  8. Winslow T, Foster E, Adams JR, Schiller NB. Pulmonary valve endocarditis: improved diagnosis with biplane transesophageal echocardiography. J Am Soc Echocardiogr 1992; 5:206.
  9. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  10. Borgeson DD, Seward JB, Miller FA Jr, et al. Frequency of Doppler measurable pulmonary artery pressures. J Am Soc Echocardiogr 1996; 9:832.
  11. Ristow B, Ahmed S, Wang L, et al. Pulmonary regurgitation end-diastolic gradient is a Doppler marker of cardiac status: data from the Heart and Soul Study. J Am Soc Echocardiogr 2005; 18:885.
  12. Lancellotti P, Tribouilloy C, Hagendorff A, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2013; 14:611.
  13. Lancellotti P, Tribouilloy C, Hagendorff A, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr 2010; 11:223.
  14. Valente AM, Cook S, Festa P, et al. Multimodality imaging guidelines for patients with repaired tetralogy of fallot: a report from the AmericanSsociety of Echocardiography: developed in collaboration with the Society for Cardiovascular Magnetic Resonance and the Society for Pediatric Radiology. J Am Soc Echocardiogr 2014; 27:111.
  15. Scapellato F, Temporelli PL, Eleuteri E, et al. Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic failure heart failure. J Am Coll Cardiol 2001; 37:1813.
  16. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr 2009; 22:975.
  17. Ristow B, Schiller NB. Obtaining accurate hemodynamics from echocardiography: achieving independence from right heart catheterization. Curr Opin Cardiol 2010; 25:437.
  18. Ristow B, Na B, Ali S, et al. Left ventricular outflow tract and pulmonary artery stroke distances independently predict heart failure hospitalization and mortality: the Heart and Soul Study. J Am Soc Echocardiogr 2011; 24:565.
  19. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010; 23:685.