Clinical introduction

A 74-year-old woman who had undergone aortic valvuloplasty, mitral valve replacement and tricuspid suture annuloplasty for combined valvular disease at the age of 44 years was referred to our hospital for the treatment of ascites and bilateral lower-leg swelling. Transthoracic echocardiography revealed severe tricuspid regurgitation due to tricuspid annular dilatation with a preserved LVEF of 60%. She was diagnosed with right-sided heart failure. Non-invasive workup studies including a lower extremity venous ultrasonography demonstrated no evidence of coexisting deep vein thrombosis as a cause of lower-leg swelling; however, in the supine position, turbulent jet flow was detected bilaterally in the superficial femoral veins with remarkable pulsations (figure 1A and see online supplementary movie I). Doppler examination showed arterial-like pulsatile flow with abnormally high peak velocity (figure 1B). However, the turbulent flow disappeared with postural change …