Results & Discussion
In 2014, the PA was 4.2 cm, in 2016 it was 4.6 cm, and in 2018 it was
4.7 cm, despite the absence of any hemodynamically significant pulmonary
stenosis. Transesophageal echocardiogram from 2018 obtained for LAA
occlusion device monitoring noted EF 65% with normal biventricular
function, a trileaflet aortic valve, and normal Sinus of Valsalva
(2.9cm)/ascending aorta (3.1cm). It did not have descriptors of PA
pressures/size. Follow-up computed tomography angiography (CTA) reported
a bicuspid pulmonic valve without stenosis and PA dilation to 4.7cm
(Figures 1, 2).
While the risk of rupture and dissection with PAAs is less than that of
aortic aneurysms, it has been reported. Therefore, care should be taken
to monitor those with a >2mm increase in size/year, a PA
pressure >50mmHg, and a diameter
>7.5cm.1 PAAs that become large enough
undetected are eventually found due to sequelae of compression of nearby
structures.2 Indications to intervene on a bicuspid
valve if stenotic include a PA systolic pressure gradient
>64mmHg and right ventricular dysfunction.1
Although our patient presented without symptoms that could be directly
attributed to a bicuspid pulmonic valve and PAA, symptomatic patients
can exhibit exertional dyspnea, weakness, cough, and
hemoptysis.2,3 In their case series of 7 patients with
isolated bicuspid disease and PAA, Izumida et al found that over half
were asymptomatic with diagnosis made on investigation of other
diseases.1
Because the patient did not meet size criteria for operative
intervention and because symptomatology was not thought to be direct
sequelae of physiologic/mass effect of the PAA, the decision was made to
continue surveillance with imaging.