Case history
Case history #1
A 78-year-old man was diagnosed with left-sided systolic heart failure 14 years ago. He was subsequently found to have atrial fibrillation, and underwent atrioventricular node ablation and pacemaker placement 10 years ago that resulted in an improvement in his left ventricular ejection fraction from 35% to 50%. He did extremely well over the years and was extremely active. Four months ago, however, he started developing chest and back tightness when pulling his cart during golfing sessions. In addition, he developed significant dyspnoea with activity and his symptoms have worsened. Now, he says his quality of life is extremely poor. He has problems walking up one flight of stairs where he experiences significant shortness of breath; even walking half a block causes shortness of breath and chest tightness. He has also noticed increased abdominal girth, early satiety, and easy fatigue.
Case history #2
A 73-year-old woman presented for the first time 5 years ago with worsening shortness of breath and lower extremity oedema. On clinical examination, she has a laterally displaced apical impulse, with a loud 3/6 holosystolic murmur at the apex. Jugular veins are distended to the angle of the jaw. Lung examination shows some bibasilar crackles. There is 2-3+ pitting edema in both lower extremities. Echocardiography shows a reduced left ventricular ejection fraction (40%), hypokinesis of the inferior and lateral walls, ischaemic mitral regurgitation (severe), and mild TR.
Other presentations
A spectrum exists such that TR may not be associated with any symptoms until a late stage of the disease involving progressive right ventricular dysfunction.[1] In some patients, moderate or severe TR may be present without the classic clinical complaints. The symptoms of left-sided cardiac disease predominate in most patients with secondary TR. The symptoms specific to advanced tricuspid valve disease are related to a reduced cardiac output and elevated right atrial pressure. Effort intolerance or dyspnoea reflects the limited cardiac reserve. Long-standing relevated right atrial pressure leads to atrial distension with reduced contractile reserve and atrial fibrillation. Often, patients with chronic severe TR will present with ascites from advanced liver disease from chronic congestion or fibrosis (cardiac cirrhosis), bowel congestion with symptoms of dyspepsia or indigestion, and fluid retention with leg oedema.[5]
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