Pulmonary regurgitation medical therapy

# Overview
Treatment of pulmonic regurgitation may be divided into medical and surgical treatment. Medical management of pulmonic regurgitation may include use of diuretics in patients with RV dysfunction. ACE inhibitors and beta blockers may be used to reverse neurohormonal activation and improve symptoms. Antibiotic prophylaxis may be indicated in certain conditions such as patients with cyanotic heart disease, prosthetic heart valves, rheumatic heart disease, and patients previously having sustained bacterial endocarditis. Among patients with carcinoid heart disease subcutaneously administered octreotide in 24 divided doses (501500 g/day) provides symptomatic and biochemical benefit.

# Medical Therapy
- There are no specific medical measures for the management of PR.
- Diuretics are recommended in patients with RV dysfunction or PAH for maintenance of fluid balance.
- Among patients with repaired tetralogy of fallot, ACE inhibitors or beta-blockers are used to reverse the neuroharmonal activation and improve the symptoms.

## Anticoagulation
- Administration of systemic anticoagulation has led to risk reduction of major thromboembolic events among patients with mechanical valves. The risks reduced from 23 per 100 patient-years to:
2.2 per 100 patient-years with antiplatelet therapy
1 per 100 patient-years with warfarin
- 2.2 per 100 patient-years with antiplatelet therapy
- 1 per 100 patient-years with warfarin
- Among patients NYHA functional class I or II and a small prosthetic clot, short-term IV unfractionated heparin or continuous fibrinolytic therapy can be administered.
- The treatment of choice for obstructive thrombosis among critically ill patients without serious comorbidity is urgent valve replacement. (European Society of Cardiology guidelines)

## Antiobiotic prophylaxis
The American Heart Association Recommendations on Prevention of Bacterial Endocarditis indicate that antibiotic prophylaxis is not necessary for pulmonic regurgitation in those patients with otherwise structurally normal pulmonic valves, particularly if there is no diastolic murmur. It should be noted, though, that those patients with the following conditions may warrant antibiotic prophylaxis:
- Complex cyanotic heart disease
- Prosthetic heart valves
- Patients with congenital heart disease and pulmonic regurgitation
- Acquired pulmonic valve regurgitation as the result of rheumatic heart disease
- Patients with complex cyanotic heart disease
- In patients who have previously sustained bacterial endocarditis
- The antibiotic prophylaxis if required is reasonable within 6 months after the procedure.
- Among patients with severe acute PR due to the large duct (such as in neonatal Ebstein's anomaly or post balloon dilation of pulmonary stenosis or perforation of valvar pulmonary atresia):
If TR accompanies the situation, a circular shunt may occur leading to poor systemic blood flow. The treatment involves stopping the prostaglandins and urgent duct ligation among unstable patients.
If tricuspid valve is competent, increasing ventilation, oxygen, and nitric oxide to cause pulmonary vasodilatation can reduce PR.
- If TR accompanies the situation, a circular shunt may occur leading to poor systemic blood flow. The treatment involves stopping the prostaglandins and urgent duct ligation among unstable patients.
- If tricuspid valve is competent, increasing ventilation, oxygen, and nitric oxide to cause pulmonary vasodilatation can reduce PR.

## Heart failure therapy
- General measures for the treatment of heart failure include:
Diet:  Salt and water restriction
Monitoring: Weight and fluid balance monitoring
Mobility: Mobility and compression stockings help prevent the development of deep venous thrombosis and leg edema.
Right heart failure: A combination of loop diuretics and digoxin (may help with right ventricular contractility). Often, loop diuretics alone are enough to achieve sufficient fluid loss, but if additional diuresis is required, the judicious coadministration of a Thiazide diuretic may be administered with loop diuretics to achieve optimal fluid balance.
- Diet:  Salt and water restriction
- Monitoring: Weight and fluid balance monitoring
- Mobility: Mobility and compression stockings help prevent the development of deep venous thrombosis and leg edema.
- Right heart failure: A combination of loop diuretics and digoxin (may help with right ventricular contractility). Often, loop diuretics alone are enough to achieve sufficient fluid loss, but if additional diuresis is required, the judicious coadministration of a Thiazide diuretic may be administered with loop diuretics to achieve optimal fluid balance.
- To read more about the medical therapy utilized in heart failure, click here.

## Carcinoid heart disease
Subcutaneously administered octreotide in 24 divided doses (501500 g/day) provides symptomatic and biochemical benefit. Octreotide (somatostatin analog) binds to somatostatin receptors, and reduces the vasoactive peptides that provoke carcinoid syndrome. Concomitant monitoring of BSL and blood glucose levels is required. Lanreotide (BIM23014, angiopeptin and somatuline) is a newer somatostatin analog, has an advantage of less frequent administrations, and can be used as an alternative to octreotide.