PMC2729471_01
(a) Transthoracic 2D echo parasternal long-axis systolic view of a flail anterior tricuspid valve leaflet (TV). Right atrium (RA) and right ventricle (RV) are labeled. The tricuspid valve annulus is not dilated, measuring 3 cm in maximum diameter. (b) Color flow Doppler demonstrating severe tricuspid regurgitation (TR).
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An echocardiogram demonstrated severe TR with a flail anterior leaflet (Figure 1), which was not previously noted.
(a) Continuous wave Doppler profile of tricuspid regurgitation in the parasternal long-axis view. The tricuspid valve regurgitant velocity is 3.61 m/s. Using the modified Bernoulli equation (DeltaP = 4V
2) and assuming a right atrial pressure of 15 mmHg, the estimated pulmonary artery systolic pressure is 67 mmHg. (b) Tissue Doppler profile of the tricuspid valve annulus demonstrates a systolic velocity of 14.5 cm/sec consistent with preserved right ventricular function.
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Estimated PA pressure had fallen to 2/3 of systemic (Figure 2(a)). The recommendation was buttressed by the presence of normal RV systolic function with normal TV tissue Doppler systolic annular velocity (Figure 2(b)) and the abrupt clinical deterioration suggesting sudden disruption of valve integrity leading to poorly tolerated severe TR. The patient was presented with the option of high-risk surgical intervention and consented to TV surgery. 
M-mode echo, parasternal short-axis, demonstrating leftward displacement of the septum during diastole (white arrows), consistent with right ventricular volume overload. Right ventricle (RV), septum (S), left ventricle (LV), posterior wall (PW), and pericardial effusion (PEF).
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RV volume overload (Figure 3). RV systolic function was unchanged, and there was no TV annular dilation.