Differential Diagnosis
The clinical presentation suggests a condition affecting the right ventricle, with signs of pressure and volume overload, decreased systolic function, and a mobile mass attached to the tricuspid valve. The differential diagnoses can be categorized as follows:
Single Most Likely Diagnosis
- Tricuspid Regurgitation due to Endocarditis: The presence of a mobile mass attached to the tricuspid valve, consistent with vegetation, in the context of right ventricular overload and dysfunction, strongly suggests infective endocarditis as the primary diagnosis. The severely increased right ventricular cavity size and moderate to severely decreased right ventricular systolic function support this diagnosis, as they are common complications of tricuspid valve endocarditis.
Other Likely Diagnoses
- Tricuspid Regurgitation due to Trauma: A history of trauma could lead to tricuspid regurgitation due to valve damage or rupture of chordae tendineae, presenting similarly.
- Pulmonary Embolism: Large pulmonary emboli can cause acute right ventricular overload and dysfunction, potentially leading to a similar clinical picture, although the mobile mass would need an alternative explanation.
- Cardiomyopathy: Certain types of cardiomyopathy, such as arrhythmogenic right ventricular cardiomyopathy (ARVC), can cause right ventricular dilation and dysfunction, but the presence of a mobile mass on the tricuspid valve would be unusual.
Do Not Miss Diagnoses
- Pulmonary Embolism with Septic Emboli: Although less likely, if the mobile mass is a septic embolus, it could indicate a pulmonary embolism with an infectious source, which is critical to diagnose and treat promptly.
- Right-Sided Heart Failure due to Constrictive Pericarditis: Constrictive pericarditis can mimic the symptoms of right ventricular overload and should be considered, especially if there's a history suggestive of pericardial disease.
- Tumor (e.g., Myxoma): Although rare, a right atrial myxoma could cause obstructive symptoms and potentially embolize, presenting with a mobile mass.
Rare Diagnoses
- Ebstein’s Anomaly: A congenital heart defect characterized by an abnormal tricuspid valve and right ventricle, which could present with similar findings, especially if undiagnosed until adulthood.
- Carcinoid Heart Disease: Involvement of the tricuspid valve by carcinoid tumors can lead to regurgitation and right heart failure, presenting with a unique set of clinical and echocardiographic findings.
- Marantic Endocarditis (Non-bacterial Thrombotic Endocarditis): Associated with hypercoagulable states or malignancy, this condition could present with valve vegetations but would typically have a different clinical context.