Severe cases may present with right-sided heart failure. P2 delayed and soft or absent. Ejection click often present and decreases with inspiration-the only right heart sound that decreases with inspiration; all other right heart sounds increase. Echocardiography/Doppler is diagnostic. Patients with peak pulmonic valve gradients greater than 60 mm Hg or a mean of 40 mm Hg by echocardiography/Doppler should undergo intervention regard less of symptoms. Otherwise, operate for symptoms. Comment and like.