Isolated Severe Tricuspid Regurgitation in a Post Pneumonectomy Patient with Chronic Atrial Fibrillation

Abstract

Severe primary tricuspid regurgitation is a rare entity, with most cases of tricuspid regurgitation being functional and secondary to pulmonary hypertension from left heart pathologies. We report an unusual case of a female patient with a history of left pneumonectomy and chronic atrial fibrillation many years earlier, and who subsequently developed tricuspid annular dilatation, resulting in severe isolated primary tricuspid regurgitation despite normal pulmonary artery pressures and left ventricular systolic function. She required multiple hospitalizations for right heart failure and continued to be NYHA class IV despite receiving maximal medical management. She finally underwent an isolated tricuspid valve ring annuloplasty, which gave her symptomatic relief. Postoperatively, she improved to NYHA class 1-II still with chronic atrial fibrillation and mild to moderate tricuspid regurgitation at the time of her death 9 years later from pneumonia. Keywords: annular dilatation, chronic atrial fibrillationAnn Thorac Cardiovasc Surg 2012; 18: 132-135 doi: 10.5761/atcs.cr.11.01682 Case ReportA 52 year old African American woman was referred with a few years history of progressively worsening exertional dyspnea and easy fatigability. She had become symptomatic at rest with orthopnea, paroxysmal nocturnal dyspnea, and chest pain radiating to the left arm and required multiple hospitalizations for right heart failure in the preceding year. She denied any history of rheumatic fever, endocarditis or chest trauma. Significant past medical history were hypertension, chronic atrial fibrillation and past surgical history of left pneumonectomy for tuberculosis 15 years earlier. Paroxysmal atrial fibrillation had developed following pneumonectomy which became chronic after 2 years despite attempts at chemical and electrical cardioversion. Physical examination was remarkable for elevated jugular venous pressure and a loud grade 5/6 pansystolic murmur maximal at the left parasternal border. Transthoracic echocardiogram (TTE) showed a markedly enlarged right atrium 8.5 cm and right ventricle with dilated tricuspid valve annulus, normal appearing leaflets and subvalvular structures with severe regurgitation grade 4/4. There was a patent foramen

A case of medical management of tricuspid regurgitation related to atrial fibrillation with constrictive pericarditis-like hemodynamics

“…In the present case, LV function was preserved with no other valvular diseases, and tricuspid annulus was dilated along with the enlargement of both atria, which are typical findings of AF-related TR. In fact, previous reports indicated that severe TR was associated with chronic AF with no fundamental abnormalities of tricuspid valve leaflets and subvalvular tissues [6].…”