Persistent Volume Overload: Constriction or Tricuspid Regurgitation?

A 73-year-old male with history of atrial fibrillation, coronary disease s/p CABG x4, ischemic cardiomyopathy (EF 40-45%) and end-stage renal disease on hemodialysis presents for evaluation of persistent volume overload. Patient has noted fluid retention, dyspnea on exertion and orthopnea despite four dialysis sessions per week. Blood pressure is 107/56, heart rate is 103 and SpO2 is 98% on room air. Physical exam is notable for irregularly irregular rhythm, 3/6 systolic murmur increased with inspiration, JVD 25cm (1-day post dialysis), ascites and 2+ peripheral edema.

Transthoracic echocardiogram shows LV ejection fraction 43%, dilated RV with moderately decreased RV function, abnormal septal bounce, severe biatrial dilation, severe mitral regurgitation and severe tricuspid regurgitation and possible tethering of RA, LA and lateral wall of LV with thickened pericardium.

Hemodynamic tracings from the patient are shown below. Figure 1A shows RA tracing while Figures 1B and 1C show simultaneous RV and LV tracings.

Figure 1

Which of the following is the most likely etiology of his findings?

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