Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 10-17: Tricuspid Regurgitation + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 and mitral valve replacement or repair is being performed (class I recommendation) Annuloplasty without insertion of a prosthetic ring (DeVega annuloplasty) may also be effective Tricuspid valve replacement Warranted when there is an inherent defect in the tricuspid valve apparatus that cannot be repaired A bioprosthetic valve is almost always used; anticoagulation is not required unless there is associated atrial fibrillation + Outcome Download Section PDF Listen +++ +++ Complications ++ Hepatomegaly Edema Ascites +++ When to Refer ++ Anyone with moderate or severe tricuspid regurgitation should be seen at least once by a cardiologist to determine whether studies and intervention are needed Severe tricuspid regurgitation requires regular follow-up by a cardiologist + References Download Section PDF Listen +++ + +Arsalan M et al. Tricuspid regurgitation diagnosis and treatment. Eur Heart J. 2017 Mar 1;38(9):634–8. [PubMed: 26358570] + +Asmarats L et al. Transcatheter tricuspid valve interventions: landscape, challenges, and future directions. J Am Coll Cardiol. 2018 Jun 26;71(25):2935–56. [PubMed: 29929618] + +Axtell AL et al. Surgery does not improve survival in patients with isolated severe tricuspid regurgitation. J Am Coll Cardiol. 2019 Aug 13;74(6):715–25. [PubMed: 31071413] + +Hahn RT et al. Anatomic relationship of the complex tricuspid valve, right ventricle, and pulmonary vasculature: a review. JAMA Cardiol. 2019 May 1;4(5):478–87. [PubMed: 30994879] + +Taramasso M et al. The International Multicenter TriValve Registry: which patients are undergoing transcatheter tricuspid repair? JACC Cardiovasc Interv. 2017 Oct 9;10(19):1982–90. [PubMed: 28982563]