Turbulent Flow in the Right Atrium: Severe Tricuspid Regurgitation or Another Rare Etiology?

Abstract

An 82-year-old, 81-kg, 188-cm man who underwent aortic valve replacement with a 25 mm bioprosthesis for aortic insufficiency returned two months after surgery with persistent fatigue and anorexia. The patient's original postoperative course was complicated by methicillin-resistant Staphylococcus aureus bacteremia that was treated with intravenous daptomycin and rifampin for 6 weeks. The patient's physical examination was notable for a new loud holosystolic murmur best heard at the left sternal border and a softer early diastolic murmur. Evidence of renal insufficiency was present (creatinine of 2.16 mg/dL), but the white blood cell count was normal. Transthoracic echocardiography demonstrated dehiscence of the prosthesis, severe tricuspid regurgitation with systolic flow reversal in the hepatic veins, and an estimated pulmonary artery systolic pressure of 76 mmHg. Transesophageal echocardiography (TEE) was performed as part of the diagnostic evaluation, and the following images were obtained (figures 1, 2, 3, and 4; video clips 1, 2, 3, and 4). What is the diagnosis? Figure 2Midesophageal aortic valve short axis TEE view View Large Image Figure Viewer Download Hi-res image