Aortic and pulmonary stenosis — branching viva

Opening: classify and grade

The candidate opens by recognising that the murmur at the upper left sternal border with a respiratory-varying ejection click and a widely split second heart sound is the classic presentation of valvar pulmonary stenosis. The click localises the lesion to the valve, its respiratory variation confirms pulmonary rather than aortic origin, and the wide S2 split reflects prolonged right-ventricular ejection. The diagnosis is confirmed by echocardiography, which shows the domed valve with fused commissures and measures the peak systolic gradient. ^{[1] [2]}

The candidate classifies the lesion by anatomic level — valvar, subvalvar, or supravalvar — and grades it by peak gradient: mild below 40 mmHg, moderate 40 to 64 mmHg, severe above 64 mmHg. The level predicts the intervention and the syndrome, and the gradient determines the urgency. This dual classification is the framework that earns marks. ^[1]

Branch 1: balloon valvuloplasty and the evidence

The examiner asks about the management of moderate valvar pulmonary stenosis. The candidate answers that balloon pulmonary valvuloplasty is the first-line and definitive intervention, one of the most successful procedures in congenital interventional cardiology, with long-term outcome data showing sustained gradient reduction and low restenosis rates. The procedure is indicated for moderate and severe gradients and for symptomatic disease. ^[2]

The examiner probes the complications. The candidate names pulmonary regurgitation as the main late concern, usually well tolerated in childhood but potentially requiring pulmonary valve replacement in adulthood. The candidate contrasts this with aortic valvuloplasty, where aortic regurgitation is the more immediate concern and the VACA Registry data established the predictors of success. ^[4]