Right Ventricular Enlargement, Moderate Tricuspid Insufficiency

[Rita]

Hello,

I am a 40-year-old female who has always been in relatively good health and am busy working and raising two young children, ages 1 and 3.  I take no medications or drugs other than an occasional aspirin. I do not smoke or drink, rarely exercise, and am of average weight. Family medical history is unavailable.

Because of some localized chest pain and irregular heart rate (gurgling/fluttering followed by a couple hard beats and cough), my family physician ordered an echocardiogram, holter monitor, and blood work.

Based on the results of the echo, I will be seeing a cardiologist in a few weeks. The results of the echo are:
   - Enlarged right ventricle to 4.0 cm.
   - 2+4+ tricuspid insufficiency
   - 35 mmHg right ventricular systolic pressure
   - Mild mitral insufficiency
Blood results are as follows:
   - ANA titer = 1:40 (borderline high)
   - ACLA -IGG and -IGM = <10 (borderline)
   - Cholesterol = 203 mg/dL (borderline high)
   - LDL = 142 mg/dL (borderline high)
   - TSH, 3rd gen. = 4.64 mu/L (high)
   - T4 = 0.92 ng/dL (normal)
   - glucose, SMA LECC, CK, CBC, and Troponin I = normal

I would like to become a bit more informed before I see the cardiologist so that we might have a better discussion.

My questions are:
   1. What would cause the right ventricle to be enlarged?  If something were wrong with my pulmonary valve, would that have shown up on the echo?
   2. What would cause tricuspid valve insufficiency?
   3. I don't understand the "2+4+" measure?
   4. Does the blood work signify anything other than I need to focus on bringing my cholesterol down and that I might have a hypothyroid?
   5. Are there any specific questions I should ask the cardiologist?
   6. Based on these results, are other tests warranted?  What kind?

I am not one to become alarmed or out of my mind with worry, but with two young children to raise, I don't want to mess around.  I need to learn/understand as much as I can to deal with the situation appropriately.  I really appreciate your time and expertise. Thank you!

Rita

[Cleveland Clinic, MD]

1. What would cause the right ventricle to be enlarged? If something were wrong with my pulmonary valve, would
     that have shown up on the echo?
A: It's probably not the pulmonary valve.  Other causes would be a ventricular septal defect, atrial septal defect and pulmonary hypertension.


     2. What would cause tricuspid valve insufficiency?
A: Probably the right ventricular enlargement is leading to the tricuspid insufficiency.

     3. I don't understand the "2+4+" measure?
A: 0 is non 4+ is the most.

     4. Does the blood work signify anything other than I need to focus on bringing my cholesterol down and that I
     might have a hypothyroid?
A: They are not normal but do not warrent treatment at this time.

     5. Are there any specific questions I should ask the cardiologist?
A: Do you want to perform a right heart cath?  What do you think is causing the elevated right sided pressures?  Do I need to see a lung specialist?

     6. Based on these results, are other tests warranted? What kind?
A: Possibly a right heart cath, probably lung studies, possibly a transesophageal echo.

[Rita]

Can you provide more information/resources about pulmonary hypertension?  Thank you.

[Cleveland Clinic, MD]

.  Pulmonary artery (PA) pressure is much like systemic blood pressure except that it is the blood pressure in the lungs.  PA pressure is  a low pressure system with the normal pressure being about 25/12 mmHg with a mean pressure of 16 mmHg.  

There are many causes of high pulmonary pressures.  The most likely cause is long standing heart valve problems. Other potential causes are chronic blood clots (pulmonary thrombosis),  congenital heart disease, obstructive lung disease, collagen vascular disease, parasitic disease involving the lung, sickle cell anemia, IV drug abuse and chronic liver disease.  If no cause of the hypertension can be found the diagnosis of primary pulmonary hypertension is made.  

The treatment of pulmonary hypertension is difficult.  Vasodilator drugs such as calcium channel blockers can be used.  Nitric oxide lowers PA pressure but only lasts for a very short time.  Flolan (Prostacyclin) lasts for a longer time but must be given intravenously and is very expensive.   Anticoagulation is recommended for patients with blood clots.   For patients who fail to respond to medical therapy the only option is lung transplantion.

www.phassociation.org

If you would like to see someone at the Cleveland Clinic I would recommend Dr. Wiederman, the head of the department.  Additional information can be found at: http://www4.clevelandclinic.org/staff/GetStaff.Asp?StaffId=1019

[Rita]

Thank you for the information.  Is there much possiblity that I might NOT have pulmonary hypertension?  (you don't have to answer).  Anyway, after I see a cardiologist on November 9th, I will consider contacting Cleveland Clinic to see Dr. Wiederman.  Thanks for the recommendation.  The cardiologist I am seeing in November is with the Thoracic Cardiovascular Institute (TCI) in Lansing, Michigan. I have received positive feedback about this group and am comfortable in going there for now.  Thank you again.  Rita

[Cleveland Clinic, MD]

Hard to say without knowing all your test results.  If you are comfortable with your docotors I see no need to get a second opinion.  If however you are interested we would be happy to see you.

[kgrelish1155]

A related discussion, Causes of enlarged right ventricle was started.