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Echo-of-the-Day Information
The Echo-of-the-Day is a presentation of 1 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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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
Echo of the Day Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
The Right is larger than the Left Side
Case#: 292
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes.
A patient presented with the following echo loops:
Case Discussion
The patient has severe tricuspid regurgitation. The RV, RA, IVC, and hepatic veins are enlarged. There is flow reversal in the RA, IVC, and hepatic veins during systole.

The differential diagnosis of tricuspid regurgitation is:

Annuluar Dilation 
Marfan's Syndrome
Rheumatoid Arthritis
Rheumatic Fever
Fen-Phen (Phentermine-Fenfluramine) or Dexfenfluramine
Tricuspid Stenosis
Myxomatous Degeneration
Congenital (Ebstein's Anomaly)
Iatrogenic (Wire, Catheter)

Tricuspid regurgitation from annular dilation is due to right ventricular dilation which is from elevated pulmonary artery pressure (pulmonary hypertension) or pulmonary stenosis. The mechanisms for tricuspid regurgitation are classified into annuluar dilation, normal leaflet motion, leaflet restriction, or excessive leaflet motion. Annular dilation is the most common cause and is usually due to a problem downstream (PS, Pulm HT, MS, MR, etc) where the RV dilates. Normal motion could indicate a perforation or annular dilation. Excessive leaflet motion indicates a papillary or chordae tendinae rupture, prolapse or flail leaflet. Restricted leaflet motion is usually due to right ventricular dilation.

Therapy for severe tricuspid regurgitation depends upon the mechanism. A repair is preferable if the annulus is dilated. A ring or a DeVega procedure can be performed. A ring has been shown to have superior long term freedom from recurrent TR. If the leaflets cannot be repaired or if restriction is present, then replacement may be the best option. Restricted valves do not lend themselves to a mitral valve repair very easily.

The mechanism in this case is restricted leaflet motion from right ventricular dilation. Therefore, a tricuspid valve replacement is indicated.

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