Tricuspid Regurgitation

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)

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