Critical role of right heart catheterization in the evaluation of the appropriateness of transcatheter repair of severe tricuspid valve regurgitation: a case report

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  HFpEF, heart failure with preserved ejection fraction; L-R, left-to-right; PAPVR, partial anomalous pulmonary venous return; PV, pulmonary vein; RA, right atrium; RHC, right heart catheterization; SVC, superior vena cava; TR, tricuspid regurgitation.

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  Figure 1. Transthoracic echocardiography. (A) Atypical four-chamber view showing severe tricuspid regurgitation. (B) M-mode showing reduced tricuspid annular plane systolic excursion (14 mm). (C) Pulsed wave tissue Doppler showing borderline right ventricular S’ (10 cm/s). (D) Speckle tracking showing reduced right ventricular four-chamber longitudinal strain and reduced right ventricular free wall longitudinal strain. (E) Continuous wave Doppler showing increased peak tricuspid regurgitant velocity (3.7 m/s) suggestive of a high probability of pulmonary hypertension.

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  Figure 2. Right heart catheterization under fluoroscopy. Oxygen saturations in the pulmonary artery, right ventricle, and right atrium are indicated. The arrow points to the tip of the Swan–Ganz catheter (course highlighted by the white dashed line) in the right pulmonary artery. PM, pacemaker (double chamber pacemaker with leads in the right ventricle and right atrium).

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  Figure 3. Right heart catherization under fluoroscopy. Oxygen saturations in the anomalous pulmonary vein and superior vena cava are indicated. The arrow points to the tip of the Swan–Ganz catheter outside of the heart (intracardiac Swan–Ganz catheter course highlighted by the white dashed line) in the pulmonary vein, which drains into the superior vena cava. PM, pacemaker; RA, right atrium.

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  Figure 4. Computed tomography reconstruction of the anatomy (similar view as fluoroscopy in Figure 3). PV, pulmonary vein; RA, right atrium; SVC, superior vena cava.

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  Figure 5. Schematic representation of the pathophysiology (simplified; the interaction between right and left ventricle is not shown). (A) Normal situation. (B) Present case (for detailed discussion, see text). AF, atrial fibrillation; LAP, left atrial pressure; mPAP, mean pulmonary artery pressure; mPAWP, pulmonary artery wedge pressure; PAPVR, partial anomalous pulmonary venous return; PBF, pulmonary blood flow; PVR, pulmonary vascular resistance; RA, right atrium; RAP, right atrial pressure; RV, right ventricle; RVSV, right ventricular stroke volume; SR, sinus rhythm; SVC, superior vena cava; TPG, transpulmonary gradient; TR, tricuspid regurgitation; n, indicates normal; (↑), borderline; ↑, elevated; ↑↑, substantially elevated.