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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Prominent v wave in jugular venous pulse

  • Systolic murmur at left lower sternal border that increases with inspiration

  • Characteristic Doppler echocardiographic findings including right ventricular volume overload, right atrial enlargement, and evidence of systolic turbulence in the right atrium

GENERAL CONSIDERATIONS

  • Tricuspid regurgitation usually occurs with a structurally normal valve; this type of functional regurgitation is often due to right ventricular and tricuspid annulus dilatation, or pressure overload

  • Functional tricuspid regurgitation is due to:

    • – Left ventricular dysfunction or mitral valve disease (usually)

    • – Pulmonary disease leading to pulmonary hypertension (less commonly)

    • – Right ventricular dysplasia (rarely)

  • Organic tricuspid regurgitation is due to:

    • – Rheumatic heart disease or bacterial endocarditis (most often)

    • – Indwelling catheters across the valve (eg, pacemaker leads) (commonly)

    • – Carcinoid involvement, tricuspid valve prolapse, or Ebstein’s anomaly (less commonly)

    • – Deceleration trauma, which can damage the tricuspid valve (rarely)

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Symptoms of the underlying disease often predominate

  • Abdominal distention, jaundice, and inanition due to hepatic engorgement

  • Peripheral edema and ascites

  • Fatigue or dyspnea, especially in patients with associated left heart disease

PHYSICAL EXAM FINDINGS

  • Elevated jugular venous pulse with an early v wave and rapid y descent, both of which are augmented by inspiration

  • Right ventricular lift along the left sternal border

  • Findings at auscultation:

    • – Right-sided S3 sound that increases in intensity with inspiration with right ventricular dilatation

    • – Right-sided S4 in those with significant right ventricular hypertrophy

    • – Early, mid, late, or holosystolic murmur at the lower left sternal border that increases with inspiration

    • – Mid-diastolic flow rumble in severe cases

  • Pulsatile enlarged liver in severe cases

  • Ascites and peripheral edema in severe cases

DIFFERENTIAL DIAGNOSIS

  • Mitral regurgitation

  • Ventricular septal defect

  • Other causes of elevated jugular veins

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Liver function tests and prothrombin time: may be elevated in severe cases

ELECTROCARDIOGRAPHY

  • ECG findings:

    • – Right atrial enlargement with or without evidence of right ventricular hypertrophy

    • – Right ventricular hypertrophy, which usually indicates pulmonary hypertension

    • – Possible atrial fibrillation

    • – Preexcitation can occur in Ebstein’s anomaly

IMAGING STUDIES

  • Chest x-ray:

    • – Right heart chamber enlargement (massive right atrial enlargement suggests Ebstein’s)

    • – Pleural effusion if right heart failure is present

    • – Elevated diaphragms if ascites present

    • – Pulmonary vascular markings possibly reduced if pulmonary hypertension is present

  • Echocardiography:

    • – Dilated right heart chambers

    • – Paradoxical septal motion with diastolic flattening, or persistent flattening if pulmonary hypertension is present

    • – The tricuspid valve may show disease or annular dilatation (>4 cm in diameter)

    • – Left heart disease may be revealed

    • – Color-flow Doppler: for ...

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