Thread by @OKiamanesh

⚡️ RIGHT VENTRICULAR FAILURE ⚡️
** MONTHLY ILLUSTRATIVE CASE X 3**

This month we present THREE CASES of severe right ventricular failure. Can you make each diagnosis?

CASE 1 - WHAT'S THE CAUSE?

CASE 2 - WHAT'S THE CAUSE?

CASE 3 - WHAT'S THE CAUSE?

Thoughts?

Answers below...

Case 1 Answer: Ebstein anomaly. The tricuspid valve is ALWAYS more apically displaced than the mitral valve. And the TV is ALWAYS associated with the RV. So we can identify the RV as the ventricular with the more apically displaced valved, 100% of the time.

In Ebstein anomaly, there is severe apical displacement of the septal and posterior TV leaflets, and variable tethering of the anterior leaflet. It's the commonest congenital cause of tricuspid regurgitation and is often associated with an atrial septal defect.

Note where the septal leaflet inserts on the septum (way up towards the apex). Also note where flow acceleration starts (by colour Doppler), identifying the origin of TR (and therefore the valve).

Case 2 Answer: Pulmonary arterial hypertension resulting in severe RV dilation and dysfunction are present. However, there are no pathognomonic echocardiographic findings of PAH.

This case illustrates the challenges that can exist in identifying the RV vs LV. Do not rely on size, shape, sidedness, or trabeculae. The only 100% reliable sign is that the RV is the ventricule with the apically displaced valve (the tricuspid).

Case 3 Answer: Carcinoid heart disease results in characteristic right sided valvular heart disease. In this case, note the severely thickened and immobile anterior and septal tricuspid valve leaflets resulting in torrential tricuspid regurgitation with laminar flow.

There you have it, folks. Three classic presentations of end-stage right ventricular failure.

Follow this account for next month's case!

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