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Archives of cardiovascular diseases
Volume 105, n° 4
pages 254-255 (avril 2012)
Doi : 10.1016/j.acvd.2011.04.015
Received : 31 Mars 2011 ;  accepted : 19 April 2011
Cyanosis due to tricuspid regurgitation
Cyanose secondaire à une fuite tricuspide

Elise Barre a, , Laurence Iserin a, Younes Boudjemline b
a Department of Adult Congenital Cardiology, European Hospital Georges Pompidou, 20, rue Leblanc, 75015 Paris, France 
b Department of Pediatric Cardiology, Necker-Enfants-Malades, AP–HP, Paris, France 

Corresponding author. Fax: +33 1 56 09 26 64.

Keywords : Transoesophageal echocardiography, Congenital cardiology, Atrial septal defect

Mots clés : Échographie transœsophagienne, Cardiopathie congénitale, Communication interauriculaire

Abbreviations : TEE

We report the case of a 59-year-old woman followed in our institution for an Ebstein anomaly; she had tricuspid valvuloplasty at the age of 56 years, associated with a cavopulmonary anastomosis. The patient presented in our unit with recent exertional dyspnea. Examination revealed no symptom of congestive heart failure at rest. Oxygen saturation was 97% at rest but fell to 85% after a 3-minute walk.

Transthoracic echocardiography showed an interatrial bidirectional flow. Contrast echocardiography was markedly positive at rest, confirming the right-to-left shunt. There was no pulmonary hypertension. The cavopulmonary shunt was difficult to visualize. Right ventricular function was good. Moderate tricuspid regurgitation was also present (grade II).

Transoesophageal echocardiography (TEE) and percutaneous shunt closure were planned for the patient. TEE demonstrated a large tricuspid regurgitation. The jet was directly orientated towards the atrial septal defect, explaining the basal right-to-left shunt (Figure 1). The shunt was closed with an Amplatzer septal occluder without complication (Figure 2) and oxygen saturation immediately rose to 99%.

Figure 1

Figure 1. 

Transoesophageal echocardiography. The jet of the tricuspid valve regurgitation is coming through the atrial septal defect, explaining the right-to-left shunt and cyanosis. LA: left atrium; RA: right atrium. Yellow arrow: atrial septal defect.


Figure 2

Figure 2. 

Transoesophageal echocardiography. The septal defect was successfully closed with an Amplatzer septal occluder (A).


In conclusion, interatrial right-to-left shunt may be unrelated to cavitary pressure regimen but explained only by the direction of the tricuspid regurgitation jet. Echocardiography, particularly TEE, is a valuable modality for identifying this specific and easily reversible mechanism of cyanosis in Ebstein patients.

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

Appendix A. Supplementary data

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