Tricuspid Regurgitation

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

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

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

• 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

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