case_images: PMC6067776_01
case_images: Right parasternal short-axis echocardiographic images of LV and RV, and long-axis four-chamber 2-D echocardiographic images.. Notes: (A and B) Right parasternal short-axis echocardiographic images showing a cross section of the LV and RV at the level of papillary muscles. (A) Severe eccentric RV hypertrophy, mild RV concentric hypertrophy, and interventricular septal flattening during systole are noted (arrows). The LV is small and underfilled, and pseudo LV concentric hypertrophy is present. (B) Four weeks after sildenafil administration. Mild concentric RV hypertrophy remains, eccentric RV hypertrophy is now mild, there is normal septal motion, and the LV is normal in dimensions. (C and D) Right parasternal long-axis four-chamber 2-D echocardiographic images. (C) Severe eccentric RV hypertrophy, mild RV concentric hypertrophy, severe RA enlargement, and moderate RPA dilation are noted. The LV is small and underfilled, pseudo LV concentric hypertrophy is present, and the LA appears normal in size. (D) Four weeks after sildenafil administration. Mild concentric RV hypertrophy remains, eccentric RV hypertrophy is now mild, and the LV subjectively appears more volume loaded. The LA is normal in size. The RA is now borderline enlarged, and the RPA remains moderately dilated.. Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RPA, right pulmonary artery; RV, right ventricle; 2-D, two-dimensional.
case_images: vmrr-6-211Fig1.jpg
case_images: PMC6067776_01_vmrr-6-211Fig1.jpg
case_images: f1-vmrr-6-211
case_images: Additionally, there were marked improvements in right heart findings, including only mild RV eccentric and concentric hypertrophy, borderline RA enlargement, normal RV ejection profiles, improved RVOT acceleration time and acceleration time/ejection time, normal interventricular septal motion, and a normal LV dimensions (Figures 1-4; Tables 1 and 2).
case_images: Right parasternal long- and short-axis 2-D echocardiographic images with color Doppler and continuous wave color Doppler at the level of the tricuspid valve, respectively.. Notes: (A) Right parasternal long-axis four-chamber 2-D echocardiographic image with color Doppler at the level of the tricuspid valve. Moderate-to-severe TR, severe eccentric RV hypertrophy, mild RV concentric hypertrophy, and severe RA enlargement are noted. The LV is small and underfilled, pseudo LV concentric hypertrophy is present, and the LA is normal in size. (B) Right parasternal short-axis 2-D echocardiographic image with continuous wave color Doppler at the level of the tricuspid valve. TR peak velocity is measured and RVESP is estimated via the modified Bernoulli's equation at 129 mmHg.. Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; RVESP, right ventricular end-systolic pressure; TR, tricuspid valve regurgitation; TR Vmax, maximum TR peak velocity; TRmax PG, maximum TR pressure gradient; V, velocity; 2-D, two-dimensional.
case_images: vmrr-6-211Fig2.jpg
case_images: PMC6067776_01_vmrr-6-211Fig2.jpg
case_images: f2-vmrr-6-211
case_images: The tricuspid valve was mildly thickened with severe tricuspid valve regurgitation present (Figures 2 and 3). The right ventricular-to-right atrial pressure gradient at the end of systole was estimated from PTRFV using continuous wave Doppler and the modified Bernoulli equation at 5.68 m/s, corresponding to an estimated right ventricular end-systolic pressure (RVESP) of 129 mmHg (approximates PASP in the absence of RV outflow obstruction) (Figure 2 and Table 2). The pulmonic valve appeared structurally normal. Additionally, there were marked improvements in right heart findings, including only mild RV eccentric and concentric hypertrophy, borderline RA enlargement, normal RV ejection profiles, improved RVOT acceleration time and acceleration time/ejection time, normal interventricular septal motion, and a normal LV dimensions (Figures 1-4; Tables 1 and 2).
case_images: Left parasternal apical four-chamber 2-D echocardiographic images.. Notes: (A and B) Left parasternal apical four-chamber 2-D echocardiographic images. (A) Severe eccentric RV hypertrophy, mild RV concentric hypertrophy, and severe RA enlargement are noted. The LV is small and underfilled, pseudo LV concentric hypertrophy is present, and the LA is normal in size. The RPA is moderately dilated. (B) Four weeks after sildenafil therapy. Mild RV concentric hypertrophy persists, mild eccentric RV hypertrophy is now present, the RA is now borderline enlarged, the RPA remains moderately dilated, and the left heart appears more preload appropriate in size. (C and D) Left parasternal apical four-chamber 2-D echocardiographic images with color Doppler at the level of the tricuspid valve. (C) Moderate-to-severe tricuspid valve regurgitation, severe eccentric RV hypertrophy, mild RV concentric hypertrophy, severe RA enlargement, and moderate RPA dilation are noted. The LV is small and underfilled, pseudo LV concentric hypertrophy is present, and the LA appears small. (D) Four weeks after sildenafil administration. Tricuspid valve regurgitation is now trace, mild concentric RV hypertrophy remains, eccentric RV hypertrophy is now mild, the RA is now borderline enlarged, the RPA remains moderately dilated, and the LV and LA subjectively appear more volume loaded.. Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RPA, right pulmonary artery; RV, right ventricle; 2-D, two-dimensional.
case_images: vmrr-6-211Fig3.jpg
case_images: PMC6067776_01_vmrr-6-211Fig3.jpg
case_images: f3-vmrr-6-211
case_images: The tricuspid valve was mildly thickened with severe tricuspid valve regurgitation present (Figures 2 and 3). Additionally, there were marked improvements in right heart findings, including only mild RV eccentric and concentric hypertrophy, borderline RA enlargement, normal RV ejection profiles, improved RVOT acceleration time and acceleration time/ejection time, normal interventricular septal motion, and a normal LV dimensions (Figures 1-4; Tables 1 and 2).
case_images: Right parasternal short-axis 2-D echocardiographic images with interrogation of the RVOT ejection envelopes/velocities with pulsed wave color Doppler.. Notes: (A) Mid-systolic notching (arrows) is noted in RVOT ejection envelopes. Moderate dilation of the main, right, and left pulmonary arteries is noted. (B) Four weeks after sildenafil administration. RVOT ejection profiles are normal in shape and laminar. Moderate dilation of the main, right, and left pulmonary arteries persists.. Abbreviations: RVOT, right ventricular outflow tract; V, velocity; 2-D, two-dimensional.
case_images: vmrr-6-211Fig4.jpg
case_images: PMC6067776_01_vmrr-6-211Fig4.jpg
case_images: f4-vmrr-6-211
case_images: Additionally, there were marked improvements in right heart findings, including only mild RV eccentric and concentric hypertrophy, borderline RA enlargement, normal RV ejection profiles, improved RVOT acceleration time and acceleration time/ejection time, normal interventricular septal motion, and a normal LV dimensions (Figures 1-4; Tables 1 and 2).