© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12673
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Exacerbation of Pulmonic Regurgitation by Diastolic Tricuspid Regurgitation Dali Fan, M.D., John N. Makaryus, M.D., Bishoy Wassef, M.D., Valentin Suma, M.D., Mina Masry, M.D., and Amgad N. Makaryus, M.D Department of Cardiology, North Shore LIJ Health System, East Meadow, New York
Few cases of diastolic mitral regurgitation (MR) and tricuspid regurgitation (TR) have been reported in the world literature. We report the case of a 63-year-old woman admitted for syncope, with a permanent pacemaker following complete heart block. Echocardiography revealed that the timing of the diastolic TR (and noted MR) coincided with the second phase of the pulmonic insufficiency (PI) jet. The respirometer revealed that the diastolic TR and the second phase of the PI are highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration). The uniqueness of this case is the rare occurrence of the exacerbation of PI as the result of diastolic TR. (Echocardiography 2014;31: E234–E239) Key words: tricuspid regurgitation, pulmonic insufficiency, echocardiography
Few cases of diastolic mitral regurgitation and tricuspid regurgitation have been reported in the world literature.1,2 Given the presence of some degree of mitral regurgitation (MR) and tricuspid regurgitation (TR) in virtually all patients with AV block, echocardiography is well-suited to noninvasively assess the atrioventricular gradient in such patients.3 Diastolic TR, due to the low pressure nature of the right ventricle, can exacerbate pulmonic insufficiency. This is the first case, to our knowledge that such a phenomenon is reported. Summary and Discussion: A 63-year-old woman was admitted to the hospital because of several episodes of syncope and near syncope in the past 3 months. Her medical history revealed complete heart block and a permanent AV sequential pacemaker placement in 1991. She had been symptom-free since. Admission physical examination auscultation revealed a systolic ejection murmur at the right second intercostal space, the left lower sternal border, and the apex. Address for correspondence and reprint requests: Amgad N. Makaryus, M.D., FACC, FACP, FASE, FSCCT, Assistant Professor, Hofstra North Shore-LIJ School of Medicine, Chairman, Department of Cardiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA. Fax: 516-572-3172; E-mail: [email protected]
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ECG demonstrated normal sinus rhythm with a first degree AV block. Transthoracic echocardiography was performed and showed normal left ventricular systolic function, mildly reduced right ventricular systolic function, mild mitral regurgitation, mild aortic regurgitation, moderate pulmonic insufficiency, and moderate tricuspid regurgitation. The continuous-wave Doppler (CW) tracing across the pulmonic valve showed a unique biphasic pattern (Fig. 1), which was absent in the CW tracings of the aortic regurgitation. CW tracings of the mitral and tricuspid valves revealed mild systolic MR with diastolic MR. CW tracings of the tricuspid valve revealed mild systolic TR with diastolic TR (Fig. 2). The timing of the diastolic TR (and MR) coincides with the second phase of the pulmonic insufficiency (PI) jet (Fig. 3). The respirometer study revealed that the diastolic TR and the second phase of the PI were highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration; Fig. 4). Therefore, we believe the second phase of the PI was actually the result of the diastolic TR. First degree AV block causes a time lapse between the end of atrial systole (end of trans-tricuspid pulse wave “A”-wave) and the beginning of ventricular systole (Fig. 5). Atrial relaxation occurs during this period of time and causes regurgitant blood flow through both the mitral and tricuspid annulus. At this moment, both the mitral and the tricuspid
Diastolic Tricuspid Regurgitation
Figure 1. The continuous-wave Doppler (CW) tracing across the pulmonic valve showed a unique biphasic pattern (arrowhead). This biphasic pattern was absent in the CW tracings of the aortic regurgitation.
valves are tethered by their respective papillary muscles and constricted in their opening position. Diastolic TR reduces the right ventricular pressure and regenerates the diminished gradient across the pulmonic valve. This results in a resurgence of the PI flow and the second phase of the PI jet. As inspiration increases blood flow to the right heart, the diastolic TR and the second phase of PI diminishes. The opposite happens during expiration (Fig. 4). This phenomenon is much less prominent in the left heart, as the transmitral pulse wave “A”-wave ends much closer to the beginning of the QRS complex (Fig. 5). There are at least three possibilities to explain this phenomenon. First, the timing of contraction and relaxation of the right atrium (RA) and left atrium (LA) may not be simultaneous, in this case, LA contraction and relaxation may occur later than RA. Therefore, diastolic MR can happen later in time and lesser in severity; but it does not cause significant exacerbation of aortic regurgitation. While this theory may be in effect in this case, the minimally increased P-wave duration of ~0.11 sec in our patient argues against this. Secondly, the PI in our patient was more substantial than the AI, and therefore likely caused a higher ventriculoatrial gradient on
the right side during diastole, and therefore caused the TR to be more significant than the MR. Thirdly, the left ventricular-aortic system, due to its high pressure nature, is much less likely to be affected by the respiration generated pressure change. The larger end diastolic gradient across the aortic valve (~50 mmHg) is much less likely to be affected by left atrial relaxation. It is interesting to note that although the patient has a pacemaker, she remained in intrinsic rhythm throughout the echocardiogram. Since it is possible to program the pacemaker with a shorter AV delay, this can be a potential solution to the diastolic MR, TR and the second phase of the PI and reduce the ventricular burden of these regurgitant flows. However, this would result in a high percentage of RV pacing and dyssynchrony. There is an interesting compromise between AV synchrony and VV synchrony. We decided that the benefit of maintaining the native rhythm outweighs the benefit of reducing the regurgitant flow and, hence, did not reprogram the AV delay. This is the first case, to our knowledge, that such a phenomenon is reported. Although the clinical significance of this phenomenon is unclear, these findings add to our understanding of the pathophysiology.
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Fan, et al
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Figure 2. A. CW tracings of the mitral valve and the tricuspid valve revealed mild systolic MR with diastolic MR (arrows). B. CW tracings of the tricuspid valve revealed mild systolic TR with diastolic TR (arrows). CW = continuous-wave Doppler; MR = mitral regurgitation; TR = tricuspid regurgitation.
E236
Diastolic Tricuspid Regurgitation
Figure 3. The timing of the diastolic TR coincides with the second phase of the PI jet (top). PI = pulmonic insufficiency; TR = tricuspid regurgitation.
Figure 4. The respirometer study revealed that the second phase of the PI is highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration; arrowheads). PI = pulmonic insufficiency.
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B
Figure 5. First degree AV block causes a time lapse between the end of atrial systole (end of trans-tricuspid Pulse Wave “A”-wave) and the beginning of ventricular systole in the tricuspid inflow A. and mitral inflow B.
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Diastolic Tricuspid Regurgitation
References 1. Schnittger I, Appleton CP, Hatle LK, et al: Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–88. 2. Sugimoto T, Okada M, Ozaki N, et al: Long-term evaluation of treatment for functional tricuspid regurgitation
with regurgitant volume: characteristic differences based on primary cardiac lesion. J Thorac Cardiovasc Surg 1999;117:463–471. 3. Kocabay G, Peluso D, Muraru D, et al: Diastolic mitral regurgitation in 2:1atrioventricular block: insight of the diastolic pressure. Echocardiography. 2013;30:E51– E52.
E239
Echocardiography
CASE REPORTS Section Editor: Brian D. Hoit, M.D.
Exacerbation of Pulmonic Regurgitation by Diastolic Tricuspid Regurgitation Dali Fan, M.D., John N. Makaryus, M.D., Bishoy Wassef, M.D., Valentin Suma, M.D., Mina Masry, M.D., and Amgad N. Makaryus, M.D Department of Cardiology, North Shore LIJ Health System, East Meadow, New York
Few cases of diastolic mitral regurgitation (MR) and tricuspid regurgitation (TR) have been reported in the world literature. We report the case of a 63-year-old woman admitted for syncope, with a permanent pacemaker following complete heart block. Echocardiography revealed that the timing of the diastolic TR (and noted MR) coincided with the second phase of the pulmonic insufficiency (PI) jet. The respirometer revealed that the diastolic TR and the second phase of the PI are highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration). The uniqueness of this case is the rare occurrence of the exacerbation of PI as the result of diastolic TR. (Echocardiography 2014;31: E234–E239) Key words: tricuspid regurgitation, pulmonic insufficiency, echocardiography
Few cases of diastolic mitral regurgitation and tricuspid regurgitation have been reported in the world literature.1,2 Given the presence of some degree of mitral regurgitation (MR) and tricuspid regurgitation (TR) in virtually all patients with AV block, echocardiography is well-suited to noninvasively assess the atrioventricular gradient in such patients.3 Diastolic TR, due to the low pressure nature of the right ventricle, can exacerbate pulmonic insufficiency. This is the first case, to our knowledge that such a phenomenon is reported. Summary and Discussion: A 63-year-old woman was admitted to the hospital because of several episodes of syncope and near syncope in the past 3 months. Her medical history revealed complete heart block and a permanent AV sequential pacemaker placement in 1991. She had been symptom-free since. Admission physical examination auscultation revealed a systolic ejection murmur at the right second intercostal space, the left lower sternal border, and the apex. Address for correspondence and reprint requests: Amgad N. Makaryus, M.D., FACC, FACP, FASE, FSCCT, Assistant Professor, Hofstra North Shore-LIJ School of Medicine, Chairman, Department of Cardiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY 11554, USA. Fax: 516-572-3172; E-mail: [email protected]
E234
ECG demonstrated normal sinus rhythm with a first degree AV block. Transthoracic echocardiography was performed and showed normal left ventricular systolic function, mildly reduced right ventricular systolic function, mild mitral regurgitation, mild aortic regurgitation, moderate pulmonic insufficiency, and moderate tricuspid regurgitation. The continuous-wave Doppler (CW) tracing across the pulmonic valve showed a unique biphasic pattern (Fig. 1), which was absent in the CW tracings of the aortic regurgitation. CW tracings of the mitral and tricuspid valves revealed mild systolic MR with diastolic MR. CW tracings of the tricuspid valve revealed mild systolic TR with diastolic TR (Fig. 2). The timing of the diastolic TR (and MR) coincides with the second phase of the pulmonic insufficiency (PI) jet (Fig. 3). The respirometer study revealed that the diastolic TR and the second phase of the PI were highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration; Fig. 4). Therefore, we believe the second phase of the PI was actually the result of the diastolic TR. First degree AV block causes a time lapse between the end of atrial systole (end of trans-tricuspid pulse wave “A”-wave) and the beginning of ventricular systole (Fig. 5). Atrial relaxation occurs during this period of time and causes regurgitant blood flow through both the mitral and tricuspid annulus. At this moment, both the mitral and the tricuspid
Diastolic Tricuspid Regurgitation
Figure 1. The continuous-wave Doppler (CW) tracing across the pulmonic valve showed a unique biphasic pattern (arrowhead). This biphasic pattern was absent in the CW tracings of the aortic regurgitation.
valves are tethered by their respective papillary muscles and constricted in their opening position. Diastolic TR reduces the right ventricular pressure and regenerates the diminished gradient across the pulmonic valve. This results in a resurgence of the PI flow and the second phase of the PI jet. As inspiration increases blood flow to the right heart, the diastolic TR and the second phase of PI diminishes. The opposite happens during expiration (Fig. 4). This phenomenon is much less prominent in the left heart, as the transmitral pulse wave “A”-wave ends much closer to the beginning of the QRS complex (Fig. 5). There are at least three possibilities to explain this phenomenon. First, the timing of contraction and relaxation of the right atrium (RA) and left atrium (LA) may not be simultaneous, in this case, LA contraction and relaxation may occur later than RA. Therefore, diastolic MR can happen later in time and lesser in severity; but it does not cause significant exacerbation of aortic regurgitation. While this theory may be in effect in this case, the minimally increased P-wave duration of ~0.11 sec in our patient argues against this. Secondly, the PI in our patient was more substantial than the AI, and therefore likely caused a higher ventriculoatrial gradient on
the right side during diastole, and therefore caused the TR to be more significant than the MR. Thirdly, the left ventricular-aortic system, due to its high pressure nature, is much less likely to be affected by the respiration generated pressure change. The larger end diastolic gradient across the aortic valve (~50 mmHg) is much less likely to be affected by left atrial relaxation. It is interesting to note that although the patient has a pacemaker, she remained in intrinsic rhythm throughout the echocardiogram. Since it is possible to program the pacemaker with a shorter AV delay, this can be a potential solution to the diastolic MR, TR and the second phase of the PI and reduce the ventricular burden of these regurgitant flows. However, this would result in a high percentage of RV pacing and dyssynchrony. There is an interesting compromise between AV synchrony and VV synchrony. We decided that the benefit of maintaining the native rhythm outweighs the benefit of reducing the regurgitant flow and, hence, did not reprogram the AV delay. This is the first case, to our knowledge, that such a phenomenon is reported. Although the clinical significance of this phenomenon is unclear, these findings add to our understanding of the pathophysiology.
E235
Fan, et al
A
B
Figure 2. A. CW tracings of the mitral valve and the tricuspid valve revealed mild systolic MR with diastolic MR (arrows). B. CW tracings of the tricuspid valve revealed mild systolic TR with diastolic TR (arrows). CW = continuous-wave Doppler; MR = mitral regurgitation; TR = tricuspid regurgitation.
E236
Diastolic Tricuspid Regurgitation
Figure 3. The timing of the diastolic TR coincides with the second phase of the PI jet (top). PI = pulmonic insufficiency; TR = tricuspid regurgitation.
Figure 4. The respirometer study revealed that the second phase of the PI is highly sensitive to respiration (attenuated with inspiration and exacerbated with expiration; arrowheads). PI = pulmonic insufficiency.
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Fan, et al
A
B
Figure 5. First degree AV block causes a time lapse between the end of atrial systole (end of trans-tricuspid Pulse Wave “A”-wave) and the beginning of ventricular systole in the tricuspid inflow A. and mitral inflow B.
E238
Diastolic Tricuspid Regurgitation
References 1. Schnittger I, Appleton CP, Hatle LK, et al: Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure. J Am Coll Cardiol 1988;11:83–88. 2. Sugimoto T, Okada M, Ozaki N, et al: Long-term evaluation of treatment for functional tricuspid regurgitation
with regurgitant volume: characteristic differences based on primary cardiac lesion. J Thorac Cardiovasc Surg 1999;117:463–471. 3. Kocabay G, Peluso D, Muraru D, et al: Diastolic mitral regurgitation in 2:1atrioventricular block: insight of the diastolic pressure. Echocardiography. 2013;30:E51– E52.
E239
