CHF & Tricuspid Valve Regurgitation

[Carolyn__0__0]

  I was hospitalized for 8 days in June, 1987.  I entered the hospital through the emergency room where they ran an EKG and diagnosed congestive heart failure.  While there, I was given an Echocardiogram (TEE).  The reason listed for the echo was:  Dyspnea; R/O Pericarditis, C/P.  The impression states:  1.Tricuspid regurgitation, severe. 2. Right atrial enlargement, right ventricular enlargement. 3. RV/Ra gradient of 27 mmHg suggesting mild pulmonary hypertension may underestimate severity.4.Pulmonic insufficiency 5.Mitral regurgitation, trivial.6. Normal LV function and wall motion.7.  No effusion.  The day after I also had a Cardiac catheterization.  Post-Cardiac Cath diagnosis was:  No evidence for intracardiac shunt;  no evidence for pulmonary hypertension; normal corocnary arteries; normal left ventricular function.  After 8 days I was sent home with a prescription for Zestril.  I was on very limited activity, 1000 mg. sodium per day, aspirin regimen, Zestril, and continued with meds I was taking before hospitalization:  50 mg. Trazodone at bedtime, 50 mg. Zoloft am.  Since arriving in St. Louis, I have consulted with a cardiologist who is following me along with a cardiac surgeon.  The surgeon suggested cardiac rehab which I began in Dec. of 1997.  I went through Phase II and Phase III and then went on to join a gym and continue my exercise regimen as follows:  30 min. treadmill at 3.5 mps with a 2.0 elevation; 10 minutes on bike at 1.9 mph (these two activities every day).  3X weekly on 5 machines on weight circuit and free weights (3 lbs.)  I have been doing great! On Mach 29,  I awakened from a sound sleep with difficulty breathing and pain in my chest and back.  I had great difficulty  breathing when lying flat.  I took Advil for pain- so uncomfortable!  All my doctor said was to lighten up on my exercise regimen and come back in one month.  I am so exhausted -- I can barely make it to the end of the driveway, let alone return to the gym!  I really wish I did feel like going because I was really enjoying the feeling of control over my own body.  Each physician who has seen me has told me my condition is extremely rare. The cardiologists in St. Louis have told me that the best course of action is for me to stay healthy, and they'll leave the valve alone and just take a "wait and see" attitude.  I honestly was quite OK with that until this episode this week.  Now I am not so sure.  I really need some direction.  

[CCF Cardio MD - MTR]

Dear Carolyn, thank you for your question.  The information you provide sounds somewhat inconsistent so I'm going to ask you some questions and in another response, I hope to help you more.  When you first presented with congestive heart failure (CHF), your echo showed normal left heart function with severe tricuspid valve regurgitation (TR). However, your cath did not show pulmonary hypertension, had normal pressures on the right side of the heart, and showed no coronary artery disease.  Those two tests provide different results so it's hard to comment on what's going on.  If you do have TR, then my first guess would be that you have pulmonary hypertension.   Pulmonary hypertension can be caused by intrinsic diseases of the lungs or pulmonary arteries, left heart failure, or from chronic blood clots to the lungs.  The pressure on the right side of the heart is normally low and blood is pumped through the right heart into the pulmonary arteries to the alveoli where oxygen is exchanged.  When the pressure in the lungs rises from one of the above conditions, the pressures in the right heart increase and the tricuspid valve begins to leak as it acts  like a "pop-off valve" for the increased pressure.  Symptoms like you describe (shortness of breath, fatigue, or swelling of the ankles) result from TR.  You sound like you were doing quite well until the recurrence and your exercise tolerance was good.  I wonder if you have had an echo repeated since your recurrent episode to determine if TR is still present.  Without that information, it's hard for me to comment on what other options would be for you.  In the meantime, however, zestril is a good drug for you and you may also need lasix, a diuretic.  Please write back and I'll try to be more thorough with more information.
Information provided in the heart forum is for general purposes only.  Specific diagnoses and therapies can only be provided by your physician.