Severe Iatrogenic Tricuspid Regurgitation

Tricuspid regurgitation (TR) is a valvular heart disease mostly associated with structural heart disease or pulmonary hypertension (PH). Rare cases of TR secondary to exposure to specific medications, such as dopamine agonists, have been described. A 50-year-old woman presented with a pituitary microprolactinoma (without surgical indication) and a history of pulmonary embolism (PE) in 2021 (risk factors included bromocriptine, which was switched to cabergoline). An echocardiogram performed one year after the PE showed no significant abnormalities. She was maintained on rivaroxaban 10 mg due to suspected chronic PE on CT angiography. She remained asymptomatic until April 2023, when she developed predominantly right-sided heart failure with dyspnoea, peripheral oedema, and ascites. She was admitted for intravenous diuretic therapy and investigation of PH, with mild symptomatic improvement. Diagnostic work-up revealed right chamber dilatation and severe TR due to annular dilatation with tethering of the subvalvular apparatus and thickened leaflets on transthoracic echocardiography, confirmed by transoesophageal echocardiography and cardiac magnetic resonance imaging. Ventilation-perfusion scintigraphy excluded chronic PE, and right heart catheterisation ruled out PH. After exclusion of alternative causes of severe TR and considering the valvular morphology and exposure to cabergoline, the drug was discontinued. Due to persistent NYHA class II heart failure symptoms, the patient underwent tricuspid valvuloplasty via minithoracotomy and has remained asymptomatic since. This case describes new-onset severe TR with right-sided heart failure in the absence of PH or chronic PE. Withdrawal of cabergoline and optimisation of volume resulted in modest clinical improvement, followed by surgical intervention with full functional recovery. This case highlights the importance of regular clinical and echocardiographic surveillance in patients receiving long-term dopamine agonist therapy, particularly cabergoline, due to the risk of valvulopathy, enabling early diagnosis and timely therapeutic intervention.