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For further information, see CMDT Part 10-17: Tricuspid Regurgitation

Key Features

Essentials of Diagnosis

  • Frequently occurs in patients with pulmonary or cardiac disease with pressure or volume overload on the right ventricle (RV)

  • Systolic c-v wave in jugular venous pulsations (JVP)

  • Holosystolic murmur along left sternal border, which increases with inspiration

  • Echocardiography useful in determining cause (low- or high-pressure tricuspid regurgitation)

General Considerations

  • Most often occurs when there is RV dilation from any cause

    • Pulmonary hypertension

    • Severe pulmonary valve regurgitation

    • Cardiomyopathy (post-MI, infiltrative disease)

    • Left heart failure

  • Less often occurs when there is an inherent abnormality of the tricuspid valve

    • Ebstein anomaly

    • Tricuspid valve prolapse

    • Carcinoid plaque formation

    • Collagen disease inflammation

    • Valvular tumors

    • Tricuspid endocarditis

  • May occur from pacemaker lead placement

Clinical Findings

Symptoms and Signs

  • Identical to symptoms and signs of RV failure due to any cause

  • Obliteration of the x descent and a positive systolic waveform noted in the JVP

  • Tricuspid regurgitation murmur: holosystolic, left parasternal, resembles mitral regurgitation but increases with inspiration

  • An S3 may accompany the murmur, related to the high flow returning to the RV from the right atrium (RA)

  • Cyanosis may develop if a patent foramen ovale opens or if an atrial septal defect is present

  • Liver dysfunction and cardiac cirrhosis are not uncommon in long-standing tricuspid regurgitation

Diagnosis

Imaging Studies

  • Chest radiograph may reveal an enlarged RA or dilated azygous vein and pleural effusion

  • The echocardiogram helps assess

    • Severity of tricuspid regurgitation

    • RV systolic pressure

    • RV size and function

    • Paradoxical motion of intraventricular septum in RV volume overload

Diagnostic Studies

  • ECG

    • Usually nonspecific

    • Atrial flutter or atrial fibrillation is common

  • Cardiac catheterization

    • Confirms the presence of the regurgitant wave in the RA and elevated RA pressures

    • If the pulmonary artery (PA) or right ventricular (RV) systolic pressure is < 40 mm Hg, primary valvular tricuspid regurgitation should be suspected

Treatment

  • Definitive treatment requires elimination of the cause of the tricuspid regurgitation

  • If the problem is left heart disease, then treatment of the left heart disease may

    • Lower pulmonary pressures

    • Reduce RV size

    • Resolve the tricuspid regurgitation

  • Treatment for primary and secondary causes of pulmonary hypertension generally reduces the tricuspid regurgitation

Medications

  • Diuretics used to manage mild tricuspid regurgitation

  • When bowel edema is present, intravenous diuretics should be used initially; if oral diuretics are then used, torsemide or bumetanide is better absorbed than furosemide in this situation

  • Aldosterone antagonists (eg, spironolactone) helpful when ascites is present

  • The efficacy of loop diuretics can be enhanced by adding a thiazide diuretic

Surgery

  • Tricuspid annuloplasty to reducing tricuspid annular dilation

    • Recommended when tricuspid regurgitation is present ...

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