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.