Anatomy Atlas

Pulmonary valve

Valva trunci pulmonalis
Also: Pulmonic valve
OrgandraftCardio

Three-cusped semilunar valve between the right ventricle and the pulmonary trunk. It is the most anterior valve, and the physiologic splitting of S2 is heard best over it.

Core anatomy

Location

At the top of the conus arteriosus (infundibulum) of the right ventricle, the most anterior and superior of the valves, behind the left 3rd costal cartilage near the sternum. verify

Parts
  • Three semilunar cusps: anterior, right and left
  • Pulmonary sinuses above each cusp (no coronary arteries arise from them)
Relations

Opens into the pulmonary trunk, which lies anterior and to the left of the ascending aorta.

Notes

Auscultation area: the 2nd left intercostal space at the left sternal border. Physiologic splitting of S2: on inspiration, increased venous return to the right heart delays pulmonic valve closure (P2), so A2 and P2 separate. This is heard best at the pulmonic area.

Mentioned in

Generated automatically from links in other entries.

Cardiac auscultation areasAortic: right 2nd intercostal space at the sternal border. Pulmonic: left 2nd intercostal space at the sternal border. Erb's point: left 3rd intercostal space. Tricuspid: left lower sternal border. Mitral: apex, left 5th intercostal space in the midclavicular line.AorticR 2nd ICS, sternal borderSternal angle (2nd rib)PulmonicL 2nd ICSErb's pointL 3rd ICSTricuspidL lower sternal borderMitral (apex)L 5th ICS, MCLMidclavicular linePatient's rightPatient's left
Cardiac auscultation areas. Classic listening posts. These are where each valve is heard best, not where the valves lie anatomically. Count interspaces down from the 2nd rib at the sternal angle.
Original schematic, created for this atlas.
View of the heart from above with the great vessels cut, showing the closed pulmonary and aortic valves and the atria
The pulmonary and aortic valves seen from above.
Henry Vandyke Carter, Gray's Anatomy of the Human Body, 20th ed. (1918), Fig. 494. Source · Public domain (Public domain in the US: published before January 1, 1931 (per Wikimedia Commons))
The four valves seen from above: pulmonary, aortic, bicuspid (mitral) and tricuspid, with the coronary arteries around them
The four valves at the base of the ventricles, with the pulmonary valve most anterior.
Henry Vandyke Carter, Gray's Anatomy of the Human Body, 20th ed. (1918), Fig. 495. Source · Public domain (Public domain in the US: published before January 1, 1931 (per Wikimedia Commons))

Clinical correlations

Pulmonic stenosis PANCE

Mechanism / lesion

Usually congenital. Associated with Noonan syndrome, tetralogy of Fallot, congenital rubella, and carcinoid heart disease.

Classic presentation

Crescendo–decrescendo systolic ejection murmur at the left upper sternal border that increases with inspiration, sometimes preceded by an ejection click. Wide splitting of S2 (delayed P2). RV heave in severe stenosis.

Abnormal splitting of S2 PANCE

Mechanism / lesion

Wide split (splitting persists but widens with inspiration): delayed RV emptying (RBBB, pulmonic stenosis). Fixed split (no change with respiration): atrial septal defect. Paradoxical split (splits on expiration): delayed LV emptying (LBBB, severe aortic stenosis).

Classic presentation

Heard at the pulmonic area; timing with the respiratory cycle distinguishes them.

Pulmonic regurgitation

Mechanism / lesion

Pulmonary hypertension (dilated annulus) or after repair of tetralogy of Fallot.

Classic presentation

Early diastolic decrescendo murmur at the left upper sternal border (the Graham Steell murmur in pulmonary hypertension).

High-yield PANCE pearls

  • Pulmonic area: left 2nd intercostal space; best place to assess S2 splitting.
  • Fixed split S2 = ASD; paradoxical split = LBBB or severe AS; wide split = RBBB or pulmonic stenosis.
  • Pulmonic stenosis ↔ Noonan syndrome, tetralogy of Fallot, carcinoid.

Imaging anatomy

X-ray

Post-stenotic dilation of the pulmonary trunk (prominent pulmonary artery segment on the left heart border) in valvular pulmonic stenosis.

MRI

Cardiac MRI quantifies pulmonary regurgitation and RV volumes, especially after tetralogy repair.

Ultrasound

Parasternal short axis at the great-artery level shows the valve and measures the gradient across it (continuous-wave Doppler).

Key views & landmarks
  • Parasternal short axis (aortic valve level) with Doppler across the RV outflow tract

Physical exam

Surface landmarks

Pulmonic area: left 2nd intercostal space at the sternal border (just below the sternal angle, to the left).

Palpation

A palpable P2 suggests pulmonary hypertension. A thrill may accompany significant stenosis.

Strength / function testing

Listen to S2 with the diaphragm during quiet inspiration and expiration to assess splitting.

Self-quiz

Q1.

A 30-year-old woman has a systolic ejection murmur at the left upper sternal border and a split S2 that does not vary with respiration. What is the most likely diagnosis?

Show answer

B

A fixed split S2 is characteristic of ASD. The systolic murmur comes from increased flow across the pulmonic valve, not from the defect itself.

Q2.

Where is the pulmonic valve best auscultated?

Show answer

B

The pulmonic area is the left 2nd intercostal space at the sternal border.

Q3.

Paradoxical splitting of S2 is most likely associated with which condition?

Show answer

C

LBBB (and severe AS) delays aortic valve closure, so A2 follows P2 and the split appears on expiration and narrows on inspiration.

Flashcards

See also