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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Biatrial Enlargement and More
Case#: 23
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
84 yo female with history of increasing SOB, DOE, HTN, pleural effusions, Paget's disease, chronic PAT. What is the diagnosis and recommended therapy? Please review some aspects of tricuspid valve repair.

Case Discussion/CME Questions
The left atrium and the right atrium are enlarged. The right ventricle is enlarged. The left ventricle is mildly enlarged. The posterior mitral valve leaflet (P2) exhibits some calcification and has some restriction of the leaflet base. The mitral valve and tricuspid valve annulus are enlarged. The leaflets do not appear to be restricted except for the calcified area around the base of P2. The aortic valve exhibits an 'en face' view but appears normal. There is a chiari formation present. A small pericardial effusion is present. The pulmonary vein systolic wave is not blunted but the left atrium is so large that the systolic wave may not be affected. The hepatic vein Doppler exhibits systolic suppression from the severe tricuspid regurgitation.

The recommended therapy would be mitral and tricuspid valve repair with a ring. Since no restriction or prolapse/flail is present, the leaflets do not need to be altered. Since the etiology is not ischemic mitral regurgitation, the repair should have a high success rate.

After the repair, the tricuspid valve has a trace of regurgitation. The mitral valve post repair regurgitation is mild to moderate and the velocity of the jet is lower velocity in that there is no aliasing present.

Tricuspid annular dilation, even in the absence of regurgitation, should be repaired in the presence of mitral regurgitation. Significant tricuspid regurgitation decreases survival and increases complications. Repair of the mitral regurgitation will not reverse the amount of tricuspid regurgitation. Severe TR is a Class 1/1C recommendation for tricuspid valve repair.

The success of tricuspid valve repair for a dilated annulus should approach 80-100% in patients who have a mitral valve repair at the same time.  Atrial fibrillation is a major factor in the progression of tricuspid regurgitation and if the annulus is not dilated and signficant TR is not present, then a MAZE procedure should be performed on patients undergoing mitral valve repair to prevent the long term consequences of unchecked atrial fibrillation and the progression of tricuspid regurgitation.

In patients who have severe mitral regurgitation, a dilated tricuspid valve annulus is a risk factor for the development of significant tricuspid regurgitation. A tricuspid annulus diameter > 4.0 cm will result in the development of clinically significant TR even if the TR is negligble at the time of the mitral valve repair.

The post repair regurgitation of the mitral valve was mild to moderate by jet area. However, the velocity of the jet was low so it was felt that the repair was adequate.

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