Tricuspid regurgitation
DEFINITION
Tricuspid regurgitation is backflow of blood from the right ventricle to the right atrium during systole.
AETIOLOGY
Congenital:
Ebstein anomaly (malpositioned tricuspid valve), cleft valve in ostium primum defect.
Functional:
Consequence of right ventricular dilation (e.g. in pulmonary hypertension), valve prolapse.
Rheumatic heart disease:
Associated with other valvular disease.
Infective endocarditis:
Common in IV drug users. Usually staphylococcal.
Other:
Carcinoid syndrome, trauma, cirrhosis (long-standing), iatrogenic (e.g. radiotherapy to the thorax).
EPIDEMIOLOGY
The epidemiology differs with various causes. Infective endocarditis probably most common cause.
HISTORY
Fatigue, breathlessness, palpitations, headaches, nausea, anorexia, epigastric pain made worse by exercise, jaundice, lower limb swelling.
EXAMINATION
Pulse:
May be irregularly irregular due to AF (may occur with right atrial enlargement).
Inspection:
" JVP with giant v waves which may oscillate the earlobe. This is caused by transmission of right ventricular pressure to the great veins. There may be giant a wave, if the patient is in sinus rhythm.
Palpation:
Parasternal heave.
Auscultation:
Pansystolic murmur heard best at the lower left sternal edge, louder on inspiration (Carvallo sign). Loud P2 component of second heart sound.
Chest:
Pleural effusion. Causes of pulmonary hypertension (e.g. emphysema).
Abdomen:
Palpable liver (tender, smooth, pulsatile), ascites.
Legs:
Pitting oedema.
INVESTIGATIONS
Blood:
FBC, LFT, cardiac enzymes, blood cultures.
ECG:
Tall P wave (right atrial hypertrophy) if in sinus rhythm. Changes indicative of other cardiac disease.
CXR:
Right-sided enlargement of cardiac shadow.
Echocardiography:
Extent of regurgitation estimated by colour flow Doppler. May be able to detect tricuspid valve abnormality (e.g. prolapse), right ventricular dilation.
Right heart catheterization:
Rarely necessary but may be considered to assess pulmonary
artery pressure.
MANAGEMENT
Medical:
Treat the underlying condition, e.g. infective endocarditis or functional regurgitation caused by pulmonary hypertension. Diuretics may be given for fluid retention.
Surgery:
Annuloplasty, plication or, rarely, replacement. Repair of the valve only in very severe tricuspid regurgitation, when the required doses of diuretics are large enough to cause metabolic consequences. Surgical removal of the valve may be required to eradicate
the source of infection in IV drug users with infective endocarditis.
COMPLICATIONS
Heart failure, hepatic fibrosis.
PROGNOSIS
Prognosis varies depending on the underlying cause.
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