MARKEDLY ENLARGED RIGHT ATRIUM ASSOCIATED WITH PHYSICAL SIGNS OF TRICUSPID REGURGITATION - A CAUSE OF CONGESTIVE-HEART-FAILURE IN THE ELDERLY

We retrospectively examined 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, and 4) structural abnormalities of tricuspid and mitral valve complexes. The subjects had a mean age of 81 years and all showed atrial fibrillation without tachycardia. Radiocardiography 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. A signal of tricuspid regurgitation was seen throughout the markedly enlarged right atrium on color Doppler echocardiography. Although neither hypoxemia nor hypercapnea were found in any of the patients, pulmonary function tests done in 6 patients were all abnormal. In chest x-ray films, 6 of the patients showed evidence of marked protrusion of the right heart border progressing over the course of several years. Right atrial enlargement due to both long-standing atrial fibrillation and presumably, to right ventricular diastolic dysfunction caused by aging made the tricuspid valve annuls annulus dilate to produce tricuspid regurgitation. In addition, concomitant mild lung disease produced a vicious cycle which led to more severe tricuspid regurgitation resulting in severe congestive heart failure. This pathophysiology can be a cause of congestive heart failure in the elderly.