History of presentation
51-year-old unrestrained female driver was involved in a high-speed motor vehicle accident 27 years ago. At that time, she had a thoracic aortic injury requiring urgent repair. Since then, the patient had developed moderate-severe tricuspid regurgitation with peripheral edema and had been taking a small dose of Furosemide.  TTE at presentation showed severe TR, right ventricular systolic pressure of 30 mmHg with normal inferior vena cava size and inspiratory collapse. TAPSE (Annulus Systolic Excursion by M-Mode) was 22 mm. Global averaged RV global longitudinal peak systolic strain (GLS) was -35%. Intraoperative transesophageal echocardiogram (TEE) showed a cresentric perforation along the basal anterior leaflet of the tricuspid valve near the annulus from 8 to 10 O’clock and central malcoaptation of leaflets causing 2 jets of severe TR (Figure 1,2) , one jet through the basal anterior leaflet perforation and the other one from the tricuspid valve malcoaptation from a markedly dilated tricuspid annulus (Figure 3) . There was hepatic systolic flow reversal (Figure 4). There was moderately enlarged right ventricular chamber size with normal RV systolic function with RV fractional area change of 54%. Based on TEE, TR appeared to have a primary and a secondary etiology. Primary etiology was likely the perforation at the tricuspid valve anterior leaflet, and as a secondary etiology was likely the progressive right ventricular (RV) remodeling from volume overload of severe TR, resuling in malcoaptation of the leaflets from annulus dilatation (5.5x 5.9 cm), causing further increase in TR.  Finally, she underwent minimally invasive tricuspid valve replacement with a 31 mm Edwards Life sciences bioprosthesis in 2019.  After surgery, follow- up TTE showed normal LV size with an LV ejection fraction of 61% and no regional wall motion abnormalities.  There was mild RV enlargement with normal RV function and an estimated RVSP of 21 mmHg. There was normal function of the tricuspid valve prosthesis with a mean diastolic gradient of 1 mm of Hg at a heart rate of 65 bpm and trivial prosthetic valve regurgitation.