Right ventricular outflow tract obstruction physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Pulmonic stenosis is an acynotic condition which may present with cyanosis when associated with interatrial right-to-left shunt. Patients are normally healthy but on auscultation an ejection systolic murmur of grade II-VI to V-VI is best heard at the left upper sternal border.

• Patients appear healthy
• A small percentage of patients have Noonan’s syndrome:

• Small stature, retarded, triangle-faced shape, webbed neck, ptosis, hypertelorism, low set ears, and pectus.
• Noonan syndrome is familial.

• If the lesion is severe (>75 mm Hg pressure gradient) then there is a giant “a wave” secondary to the reduced compliance of the right ventricule, otherwise JVP is normal.

• Right ventricular heave or lift is present in moderate to severe pulmonary stenosis.
• A precordial thrill is present in case of severe obstruction at the left suprasternal notch and the left upper sternal border.

• First heart sound (S1) is normal or loud.
• Second heart sound (S2) is widely split.

• In mild forms, the pulmonic component of the second heart sound is loud.
• In severe forms, the pulmonic component of the second heart sound may be missing.

• Fourth heart sound (S4) is heard at the left lower sternal border in presence of severe stenosis.
• Ejection click is often present and best heard at the left sternal border. Loudness of the click decreases with inspiration.

• There is a loud systolic ejection murmur loudest in the second left intercostal space which peaks in late systole.
• It radiates into axillae and back.
• Severe stenosis is clinical assessed by:

• long duration and late peaking of the ejection systolic murmur,
• short interval between the first heart sound (S1) and ejection click,
• increase in width between aortic (A2) and pulmonic component (P2) of the second heart sound (S2), and
• soft pulmonary component of second heart sound (P2)

• Other murmurs:

• Severe pulmonary stenosis can lead to tricuspid regurgitation which results in an holosystolic murmur best heard at the left lower sternal border.
• An associated pulmonary regurgitation will result in an early diastolic decrescendo murmur.

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