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Case History :

32-year-old female presented with exercise intolerance during a pregnancy. She was apparently well and not cyanotic. She had been operated for scoliosis in the past. There was no prior history of cardiac disease.

On examination her Bp 90/60 mmHg and Pulse 72/minute and regular, JVP normal and Precordial exam normal. On auscultation she had Grade 3-pansystolic-murmur maximal at the apex and Grade 3-ejection systolic murmur of medium length maximum at LUSB. Single loud second sound. No gallops. Angiography showed Systemic right ventricular injection showed moderate dilation, moderate dysfunction, and moderate systemic tricuspid regurgitation.

Pulmonary left ventricular injection showed normal pulmonary left ventricular function with a thickened pulmonary valve and post-stenotic dilation of the main pulmonary artery.

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Investigation Reports :

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Discussion :

This 32 year old woman has congenitally corrected TGA with mild pulmonic valve stenosis and moderately severe systemic tricuspid regurgitation. She is doing well clinically on digoxin, enalapril, and furosemide. She has a grade 3 murmur of systemic tricuspid regurgitation and a grade 3 murmur of pulmonary left ventricular outflow tract obstruction. A systemic tricuspid valve replacement was elected to protect her systemic right ventricle.Not only do we believe that tricuspid valve replacement should be considered - we believe that early referral and intervention is even more important in such cases where the regurgitation is clearly severe, and the systemic right ventricle is clearly compromised.

This patient did go to tricuspid valve replacement. The surgeon approached through a leftsided left atriotomy. The tricuspid valve was primarily dilated with some deterioration of the leaflets with thickening and limitation of movement. Repair was not attempted. It was excised, leaving as many chordal attachments to the papillary muscle as possible. A 29 mm st. jude mechanical valve was inserted. Her postoperative course was uneventful.

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