Enlarged right ventricle with trace tricuspid regurgitation

[Carol_123]

I am a worried mother waiting to see a pediatric cardiologist hoping to get an opinion on her echo. My daughter is 3.5 yrs old and was screened due to her being underweight (she was 1m premature with no health issues), a heart murmur and frequent coughing and allergies. She weighs 27lbs however both sides of the family have small children but she has been growing at regular intervals, just underweight for her age.

Study Findings: referred for evaluation of heart murmur.
Left Ventricle: Normal cavity size. Normal wall thickness. Normal systolic function.
Left Atrium: Normal size for age.
Right Ventricle: Mild-to-moderately enlarged right ventricular cavity.
Tricuspid Valve: Trace tricuspid regurgitation present. The right ventricular systolic pressure, as measured by Doppler is 25 mml-lg.
Pulmonary Valve: appears structurally normal, physiologic degree of pulmonary imaged.
Pulmonary Veins: The left pulmonary veins return to the left atrium: the right veins were not well imaged.
Coronary Arteries: Normal coronary pattern.

Conclusions:
1. Mild to moderately enlarged right ventricular cavity
2. Normal biventricular function
3. No evidence of significant valvar regurgitation or stenosis.
4. No obvious PFO, VSD or PDA.
5. No outflow tract obstruction.
6. Unobstructed left aortic arch.
7. Suggest referral to pediatric cardiologist.

I would love to know what this all means. Is this just something we need to watch or is there something really wrong here. Due to her almost constant coughing, is this the heart putting fluid in the lung or can something like possible asthma be causing the cough and can that put pressure on her heart? We are due to travel out of the country in a month and I don't know if we should be taking her anywhere but do want to go just to see if it is something in our house causing her to cough. We have cats and dogs but she doesn't test positive to a skin test.

Thanks

[Marie M Gleason, M.D.]

If a child is uncooperative for an echocardiogram, of course, all interpretation is subject to error. When we look at echocardiograms, the interpretation of whether or not the right ventricle is enlarged is not based on an absolute number, but rather, on how it looks compared to the other pumping chamber.  So these numbers are not particularly helpful, except to say that the measurement of the RV is smaller than the LV in the plane in which it was measured.  If your primary doctor wants to do more work up prior to the visit with the cardiologist, then they could get an ECG (to see if that shows signs of RV enlargement) and a chest xray to see if the heart looks enlarged and the blood flow to the lungs looks increased. Aside from these things, you will need to wait until you see the pediatric cardiologist and get their opinion.  It sounds like your child is quite functional and we would not expect any changes to occur acutely.  Good luck.

[Carol_123]

Thank you so much. I realize you can't say a therapy without knowing a cause but I am curious as to whether there is a possibility that a second echo could come back normal? Is there a rate of error when imaging a young squirmy underweight 3.5 yr old? Are there children with enlarged right ventricles with no cause that is just a variant of normal for them needing no intervention? It's going to be awhile before I get any answers waiting to see the cardiologist, and then for more testing, so I am just trying to understand the possibilities and treatments for each so I'm not automatically assuming the worst case scenario - surgery and its possible complications, but also don't want to hope for some miracle that isn't going to happen.

I ask this because we have seen numerous new doctors who are alarmed by my daughter's weight, being of abnormal size in body weight, "failure to thrive" because she doesn't meet any normal distribution in terms of her size. She was one month premature with no health issues at that time and both myself and my husband were and have small babies. She is 26 lbs, 36" tall and growing at regular intervals (family Dr. not concerned) and is extremely active and healthy outside of her allergies and couple bouts of pneumonia/bronchitis. Since she is of abnormal size in body weight percentiles, could her heart be viewed as abnormal as well according to the charts, but normal for her?

I've included some measurements from the echo rounded into inches for you:

2D/M mode:

AoDiam 1.4cm (0.551")
LaDiam 1.9cm (0.748")
RVIDd 1.9cm (0.748")
IVSd 0.4cm (0.1575")
LVIDd 2.9cm (1.142")
LVPWDd 0.5cm (0.197")
EF(Terch) 70%

[Marie M Gleason, M.D.]

It sounds like either the pediatric cardiologist will need to repeat the echo and see if they can find a cause, or they will need alternative imaging, often a cardiac MRI.  PAPVR can be missed by echo unless you are really looking for it.  A Sinus venosus type ASD can be missed if the echocardiogram is not specifically looking for it.   of course, I cannot say what the therapy will be until a cause is found. Occasionally a cough can be associated with such things, but often it is unrelated.

[Carol_123]

Thank you! So I am to understand that whatever it is causing the enlarged right ventricle, it will need a surgical or device repair?

Since there was no mention of her having ASD (PFO) or PAPVR on the echo will she need an MRI or CT scan to evaluate for these? I'm not familiar with what should show up on each test if she has either defect ie. if they didn't see ASD on this echo does that mean she doesn't have one or does it mean she needs a more sensitive test? Is an echo unable to pick up PAPVR needing what test next?

Can this heart condition be causing her frequent coughing episodes?

[Marie M Gleason, M.D.]

From what you have posted about your child's echocardiogram report, the main finding is that the right sided pumping chamber (right ventricle) is enlarged, and it should not be.  Common causes for this in childhood are a hole in the wall between the upper heart chambers (ASD), and partially anomalous drainage of the right pulmonary veins to the right side of the heart (PAPVR).  The trivial tricuspid regurgitation is normal in children and the report suggest that the pressure in the lungs is normal. The cause of the right sided heart enlargement needs to be sorted out by a pediatric cardiologist. Usually this is not an emergency.  Some forms of congenital heart disease are not picked up until the children are a bit older and then you hear the heart murmur. If it is an abnormality of the pulmonary venous returm, that is repaired surgically. If it is an ASD, some are closed surgically and others can be closed by devices (but I cannot tell from the echo report because it suggests that there is no ASD by saying there is no PFO).... I don't know how soon your appointment is with the cardiologist, but if it is far away, make sure your pediatrician checks your child's oxygen level (pulse oximetry) and does a chest xray to see if the heart is enlarged.  Depending upon where you are planning to go out of the country and for how long, it might be best to get the evaluation done BEFORE you go away. As far as your concern about allergies, that should not make the heart chambers enlarge.