The Influence of Loud Crying On Pulmonary Gradients Obtained By Transthoracic Echocardiography In Children With Pulmonary Valve Stenosis

Pulmonary valve stenosis (PS) is the obstruction of blood outflow from the right ventricle of the heart at the level of the pulmonary valve. Crying is associated with an increase in venous return and it has been known to have some acute effects on cardiovascular system, the data about the alterations in echocardiographic findings during crying is limited. To explore the influences of loud crying in evaluation of transvalvular gradient obtained by Doppler echocardiography in children with pulmonary valve stenosis (PS). Our study group included a total of 48 children, aged between 2 and 43 months who were diagnosed with pulmonary valve stenosis based on the clinical signs and laboratory (Echocardiography) findings in our hospital. We compared the pulmonary gradients obtained by echocardiography while the children were crying and while they were calm. Totally 48 patients (23 male, 25 female) diagnosed with PS in our hospital were included in the study. The mean age of the patients was 19.27 ± 11.14 months (range: 2-43 months). During crying, both maximum and mean pulmonary gradients were statistically significantly higher compared with the results obtained while the patients were calm (p < 0.001, p = 0.001, respectively). In conclusion, significant increases in both maximum and mean pulmonary gradients were determined during loud crying. Since these parameters are the main determinants of management of patients with PS, this condition should be kept in mind and if possible these measurements should be obtained while the children are in a calm state. Larger prospective studies are warranted to support our findings.

PDF

___

1. Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. First of two parts. N Engl J Med 2000; 342: 256-263.

2. Waller BF, Howard J, Fess S. Pathology of pulmonic valve stenosis and pure regurgitation. Clin Cardiol 1995; 18: 45-50.

3. Odenwald T, Taylor AM. Pulmonary valve interventions. Expert Rev Cardiovasc Ther 2011; 9: 1445-1457.

4. CJ Bruce, HM Connolly. Right-sided heart deserves a little more respect. Circulation 2009; 119: 2726-2734.

5. Roest AA, Kunz P, Lamb HJ, et al. Biventricular response to supine physical exercise in young adults assessed with ultrafast magnetic resonance imaging. Am J Cardiol 2001; 87: 601-605.

6. Picano E, Pibarot P, Lancellotti P, et al. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol 2009; 54: 2251-2260.

7. Ludington-Hoe SM, Cong X, Hashemi F. Infant crying: nature, physiologic consequences, and select interventions. Neonatal Netw 2002; 21: 29- 36.

8. Sakuragi S, Sugiyama Y, Takeuchi K. Effects of laughing and weeping on mood and heart rate variability. J Physiol Anthropol Appl Human Sci 2002; 21: 159-165.

9. Hendriks MC, Rottenberg J, Vingerhoets AJ. Can the distress-signal and arousal-reduction views of crying be reconciled? Evidence from the cardiovascular system. Emotion 2007; 7: 458-463.

10. Rottenberg J, Chambers AS, Allen JJ, et al. Cardiac vagal control in the severity and course of depression: the importance of symptomatic heterogeneity. J Affect Disord. 2007; 103: 173- 179.

11. Javorka K, Tomori Z, Zavarská L. Mechanics of breathing during sneezing and crying in premature newborns. Eur J Respir Dis 1982; 63: 442-448.

12. De Meester P, Buys R, Van De Bruaene A, et al. Functional and haemodynamic assessment of mild-to-moderate pulmonary valve stenosis at rest and during exercise. Heart 2014; 100: 1354-1359.

13. Thapar MK, Rao PS. Significance of infundibular obstruction following balloon valvuloplasty for valvar pulmonic stenosis. Am Heart J 1989; 118: 99-103.

14. Rodbard S, Ikeda K, Montes M. An analysis of mechanisms of post stenotic dilatation. Angiology 1967; 18: 349-367.

15. Koretzky ED, Moller JH, Korns ME, et al. Congenital pulmonary stenosis resulting from dysplasia of valve. Circulation 1969; 40: 43-53.

16. Prabhu MR. Trans-esophageal echocardiography for tricuspid and pulmonary valves. Ann Card Anaesth 2009; 12: 167.

17. Chen CR, Cheng TO, Huang T, et al. Percutaneous balloon valvuloplasty for pulmonic stenosis in adolescents and adults. N Engl J Med 1996; 335: 21-25.

18. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008; 118: 714-833.

19. Lima CO, Sahn DJ, Valdes-Cruz LM, et al. Noninvasive prediction of transvalvular pressure gradient in patients with pulmonary stenosis by quantitative two-dimensional echo Doppler studies. Circulation 1983; 67: 866-871.

20. Lurz P, Muthurangu V, Schuler PK, et al. Impact of reduction in right ventricular pressure and/or volume overload by percutaneous pulmonary valve implantation on biventricular response to exercise: an exercise stress real-time CMR study. Eur Heart J 2012; 33: 2434-2441.