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Quadri-leaflet pulmonary valve: unusual cause of unexplained murmur
  1. G C Smith,
  2. R H Mohiaddin

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A 43 year old woman was referred for cardiac magnetic resonance (CMR) imaging for investigation of a systolic murmur.

The patient was asymptomatic with no previous episodes of chest pain, breathlessness, palpitations, or syncope. Her exercise tolerance was good. There were no risk factors for ischaemic heart disease, no history of hypertension or diabetes, and she had never smoked.

On examination she was well with no jaundice, cyanosis, anaemia, or clubbing. She was normotensive and in sinus rhythm. The jugular venous pressure (JVP) was not elevated. On auscultation she had a loud pansystolic murmur audible throughout the precordium but did not radiate elsewhere. There were no carotid bruits.

Her resting ECG was normal as was a recent computed tomographic (CT) chest scan. Her echocardiogram was reported as normal. The murmur was therefore assumed to be “innocent” but the patient was referred to CMR Unit, Royal Brompton Hospital, to rule out a small ventricular septal defect (VSD).

We performed standard multislice acquisitions in all tomographic planes and cine imaging of cardiac structures in their long and short axes. Cine imaging revealed an area of turbulence emanating from the pulmonary valve. Further cine imaging with and without flow mapping (panel below) revealed a four leaflet pulmonary valve which was not significantly stenosed (peak velocity 1.6 m/s). Mild pulmonary valve regurgitation was noted. Abnormalities of the pulmonary valve are relatively common.

There are few previous reports of a four leaflet pulmonary valve but, to our knowledge, this is the first report demonstrated by CMR. The systolic murmur auscultated is presumed to arise from the increased turbulence generated by disturbed flow through this valve and its close proximity to the anterior chest wall.

Embedded Image

Selected cine images in the short axis of the pulmonary valve acquired in diastole (A) and systole (B), showing a four leaflet pulmonary valve (arrow) and a rectangular orifice.