Author + information
- Received February 26, 2013
- Revision received May 1, 2013
- Accepted May 6, 2013
- Published online October 22, 2013.
- Sushma Rekhraj, MBChB,
- Duncan C. McNab, MPhil,
- Leonard M. Shapiro, MD,
- Stephen P. Hoole, MD and
- Bushra S. Rana, MD
A 70-year-old woman presented with breathlessness, hypoxia, right heart failure, and diarrhea. On transthoracic echocardiography, the tricuspid valve leaflets were thickened, severely retracted, and immobile (A and B, Online Videos 1, 2, and 3) with severe tricuspid regurgitation. Additionally, the mitral, aortic (C, Online Videos 4 and 5) and pulmonary valves had thickened leaflets and severe regurgitation. Carcinoid syndrome was suspected and confirmed with elevated urinary 5-hydroxyindoleacetic acid levels of 491 μmol/day (normal range, 0 to 47). However, the cause of hypoxia was unexplained. Computed tomography of the chest showed multiple but small pulmonary emboli out of proportion to the degree of hypoxia and no carcinoid lung metastases. Three-dimensional transesophageal echocardiography revealed shunting of the tricuspid regurgitation jet across a large patent foramen ovale (PFO) into the left atrium (D, white arrow, and E, left atrial view, PFO opening denoted by dotted line, Online Videos 6 and 7). Percutaneous closure of the PFO with a 30-mm Gore Helex Septal Occluder (W. L. Gore & Associates, Inc., Flagstaff, Arizona) resolved the hypoxia (F, arrow, Online Video 8).
- Received February 26, 2013.
- Revision received May 1, 2013.
- Accepted May 6, 2013.
- American College of Cardiology Foundation