Markedly enlarged right atrium associated with physical signs of tricuspid regurgitation: A cause of congestive heart failure in the elderly

Kanji Iga MD, Takashi Konishi MD, Tadashi Matsumura MD, Tadashi Miyamoto MD, Kazuhisa Kijima MD and Hiromitsu Gen MD

Summary

We retrospectively selected 8 patients who had classical physical signs of tricuspid regurgitation associated with congestive heart failure, the cause of which was not identified by echocardiography. Exclusion criteria were as follows. 1) Peak velocity of tricuspid regurgitation greater than 3 m/sec. 2) Disturbance of left ventricular wall motion. 3) Severe mitral regurgitation and/or aortic regurgitation by color Doppler echocardiography. 4) Structurally abnormalities of tricuspid and mitral valve complexes.

Subjects were elderly with a mean age of 81 years and all had atrial fibrillation without tachycardia. Radiocardiogram showed no significant left-to-right shunt. Two-dimensional echocardiography showed a markedly enlarged right atrium and slight enlargement of the right ventricle in all patients. Tricuspid regurgitation signal was seen throughout the markedly enlarged right atrium on color Doppler echocardiography. Although there were neither hypoxemia nor hypercapnea in all patients, pulmonary function tests done in 6 patients were all abnormal. Six of all patients had an evidence of marked protrusion of the right heart border in chest film progressing over several years.

Right atrial enlargement due to both long-standing atrial fibrillation and presumably to right ventricular diastolic dysfunction by the aging process made tricuspid valve annuls dilate and cause tricuspid regurgitation. In addition, concomitant mild lung disease made a vicious cycle leading to more severe tricuspid regurgitation resulting in severe congestive heart failure. This pathophysiology can be a cause of congestive heart failure in the elderly