Tricuspid regurgitation usually presents with fatigue, dyspnea, and lower extremity edema. Additional complaints may include abdominal distension and early satiety.
Mild or moderate tricuspid regurgitation without abnormal valve anatomy, ventricular function, or pulmonary artery pressure is not necessarily abnormal but is estimated to be present in over 50% of asymptomatic young adults.
The clinically most important form is secondary to left-sided cardiac disease, with tricuspid annular dilation.
The affected valve may be repaired or replaced; similar to mitral surgery, surgical repair is preferred over replacement.
Operative risk for tricuspid valve surgery depends on the extent of right ventricular dysfunction and concomitant disease. Reoperation for severe tricuspid regurgitation after left-sided valve surgery carries a high risk. Therefore, correction of tricuspid regurgitation should be considered at the time of initial surgery.
The disease has largely been undertreated and its impact is under appreciated.
Tricuspid regurgitation (TR) occurs when blood flows backwards through the tricuspid valve. In the vast majority of patients, this occurs during systole, but severely elevated right ventricular filling pressure can be associated with diastolic TR. TR can be primary (abnormal valve morphology) or secondary (normal valve morphology). Some degree of valvular regurgitation is a relatively common incidental finding in color Doppler imaging. In fact, two-dimensional echocardiography has demonstrated that 50% to 60% of asymptomatic young adults exhibit mild tricuspid regurgitation. A smaller proportion, up to 15%, have moderate tricuspid regurgitation.
History and exam
Key diagnostic factors
- fatigue and effort intolerance
- jugular venous abnormality
- irregular heart rhythm
- parasternal systolic murmur
- increased systolic murmur on inspiration (Carvallo sign)
- peripheral edema
Other diagnostic factors
- abdominal distension
- early satiety, dyspepsia, or indigestion
- liver and systemic venous pulsation
- left-sided heart failure
- dilated tricuspid annulus
- rheumatic heart disease
- permanent pacemaker
- carcinoid heart disease
- pacemaker lead entrapment
- ischemic cardiomyopathy
- constrictive pericarditis
- congenital heart disease
- rheumatoid arthritis
- radiation therapy
- Marfan syndrome
- tricuspid valve prolapse
1st investigations to order
- transthoracic or transesophageal echocardiogram
- serum BUN and creatinine
Investigations to consider
- operative transesophageal echocardiogram
- postoperative transthoracic echocardiogram
- cardiac catheterization
- cardiac MRI (preferred technique for evaluation of right ventricular size and function)
primary: mild or moderate
secondary: mild or moderate
- 2022 AHA/ACC/HFSA guideline for the management of heart failure
- 2020 ACC/AHA guideline for the management of patients with valvular heart disease
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