Torrential Tricuspid Regurgitation With Massive Right Ventricular Dilation and Circumferential Pericardial Effusion: Hemodynamic Surprises and Management Dilemmas

Document Type

Conference Proceeding

Publication Date

4-7-2026

Publication Title

Journal of the American College of Cardiology

Abstract

“forgotten valve,” has gained recognition due to its complex risk factors and challenging management. Torrential tricuspid regurgitation (TR) carries high morbidity and mortality. We present a case of torrential TR with a very large pericardial effusion, managed with pulmonary artery catheter-guided pericardiocentesis. This highlights the role of advanced hemodynamic monitoring, including right ventricle (RV)-pulmonary artery (PA) coupling and pulmonary artery pulsatility index (PAPi), in guiding therapy for high-risk RV failure. CASE A 73-year-old man presented with diarrhea and fatigue. CT revealed a large circumferential pericardial effusion. Echocardiography showed a severely dilated RV, torrential TR (PISA 1.8 cm; EROA 2.19 cm2 ; regurgitant volume 212 mL; regurgitant fraction 85%), retracted leaflets, and large effusion without tamponade. Carcinoid work-up was negative. One month later he re-presented with worsening dyspnea and edema. Right heart catheterization prior to drainage showed right atrium (RA) 26 mmHg, opening pericardial pressure 10 mmHg, mean PAP 25 mmHg, PAPi 0.61, RV-PA coupling 0.20, cardiac output 4.11 L/min, and cardiac index 2.39 L/min/m2 . Pericardiocentesis removed 500 mL serosanguineous fluid, reducing RA to 16 mmHg. Unclamping the drain triggered hypoxia, hypotension, and tachycardia, which improved with re-clamping. Echocardiography revealed worsening RV dilation and left ventricular compression. Conservative diuresis restored renal function and stabilized hemodynamics. He declined tricuspid intervention and was discharged on guideline-directed therapy. DECISION-MAKING Management required balancing relief of pericardial pressure with preservation of RV filling. Hemodynamic parameters guided cautious drainage and subsequent conservative diuresis. CONCLUSION Pericardial drainage in severe TR and RV failure can be detrimental if not performed under close hemodynamic monitoring of right sided and pericardial pressures. The changes in transmural pressure must be trended and individualized strategies are essential in managing these high-risk patients.

Volume

87

Issue

13 Suppl

First Page

A1941

Comments

American College of Cardiology 75th Annual Scientific Session & Expo, March 28-30, 2026, New Orleans, LA

Last Page

A1941

DOI

10.1016/j.jacc.2026.02.4836

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