Thyrotoxic Valvulopathy: Case Report and Review of the Literature

Abstract

We report a 42-year-old female who was admitted for abdominal pain, and also endorsed dyspnea, fatigue and chronic palpitations. Past medical history included asthma, patent ductus arteriosus repaired in childhood and ill-defined thyroid disease. Physical examination revealed blood pressure of 136/88 mm Hg and heart rate of 149 beats per minute. Cardiovascular exam revealed an irregularly irregular rhythm, and pulmonary exam revealed mild expiratory wheezing. Abdomen was tender. Electrocardiogram revealed atrial fibrillation with rapid ventricular response which responded to intravenous diltiazem. Labs revealed TSH of < 0.1 mU/L and free T4 of 2.82 ng/dL, a positive TSH-receptor and thyroid peroxidase antibodies suggesting Grave’s thyrotoxicosis. A transthoracic echocardiogram reported an ejection fraction of 55-60%, with mild to moderate mitral regurgitation (MR) and moderate to severe tricuspid regurgitation (TR) and dilated right heart chambers. Pulmonary artery systolic pressure was 52 mm Hg. Transesophageal echocardiogram revealed a myxomatous tricuspid valve with thickening and malcoaptation of the leaflets and moderate to severe TR, mild to moderate MR with mild thickening of the mitral valve leaflets. Abdominal ultrasound revealed wall thickening of the gall bladder concerning for acute cholecystitis. She underwent laparoscopic cholecystectomy and was discharged in stable condition on methimazole for her thyroid disease, and on oral diltiazem for rate control and anticoagulation for atrial fibrillation. Follow-up visit with her cardiologist few months later documented absence of cardiac symptoms, and no murmurs were reported on physical examination. This case underscores the importance of maintaining a high index of suspicion for hyperthyroidism when faced with significant newly diagnosed pulmonary hypertension and TR, as treatment of the thyroid abnormalities can reverse these cardiac findings.

Right Heart Failure and Hyperthyroidism: A Neglected Association

“…Thyroid hormones increase right ventricular preload by increasing venous return which contributes to its dilation [7,6]. Our patient exhibited a functional tricuspid regurgitation with structurally normal leaflets.…”

Hyperthyroidism with Biventricular Heart Failure and Cirrhotic Transformation of the Liver

“…In their study of thyrotoxic heart disease patients, Wu et al noted 63% to have heart failure, 60% to have MR and TR, and 44% to have PH [5]. In uncontrolled hyperthyroidism, impaired collagen metabolism may lead to myxomatous leaflet and chordae degeneration, with subsequent MR [3, 4, 11, 12]. Another probable cause of valvulopathy is the hemodynamic changes in thyrotoxicosis, including increased venous return and dilatation of cardiac chambers and valve annulus [2, 13].…”

“…Of the various manifestations of thyrotoxicosis, our patient presented with atrial fibrillation and tachycardia-induced cardiomyopathy, severe valvular disease, and PH, which was further complicated by congestive liver injury as evident by abdominal ascites with a SAAG >1.1. In contrast to primary PH that carries a poor prognosis and has limited treatment options, PH due to Graves' disease carries a good prognosis, with prior reports of resolution after appropriate treatment [3, 6, 11, 14], emphasizing the importance of early recognition. Also, it is very rare for hyperthyroidism-driven heart failure to lead to cirrhosis, and cirrhosis has been reported mostly in chronic right heart failure [18].…”

Alteraciones cardíacas en los pacientes con enfermedad tiroidea

“…En el artículo Thyrotoxic valvulopathy: case report and review of the literature se comenta el caso de una paciente que presentó una válvula tricúspide mixedematosa con regurgitación tricuspídea 24 . En el mismo se comenta sobre reportes de caso similares, que se han presentado en pacientes con alguna valvulopatía, la cual ha sido resuelta luego del tratamiento adecuado para el hipertiroidismo 24 . Se cree que la regurgitación tricuspídea está causada por la dilatación del ventrículo derecho secundaria al aumento del retorno venoso.…”

“…Esto se fundamenta en que la degeneración mixomatosa se caracteriza por una apariencia desordenada de haces de colágeno, que finalmente conducen a un tejido que se estira y se rompe con mayor facilidad. Así mismo, en las tirotoxicosis, como en la enfermedad de Graves, se han reportado muchos efectos sobre el tejido conectivo de las válvulas tricúspides que conducirían a una degeneración mixomatosa 24 .…”