Tricuspid Valve Regurgitation

Introduction

Tricuspid valve regurgitation occurs when blood abnormally flows backwards from the right ventricle into the right atrium through a diseased tricuspid valve.

Tricuspid regurgitation can be organic from actual valve or leaflet damage, or functional from tricuspid annular dilation. Even in the setting of severe tricuspid regurgitation, right heart failure may not develop. Historically, tricuspid valve excision was performed to remove bacterial vegetations. This results essentially in “wide-open” tricuspid regurgitation and most patients did clinically well. 

Etiology

Functional tricuspid regurgitation is the most common etiology. This occurs due to any cause of pulmonary hypertension which in turn results in increased right ventricular pressure dilating the tricuspid valve annulus.

Rare causes include pacemaker lead leaflet damage, damage from heart biopsies (heart transplant patients), carcinoid valve disease, tricuspid valve prolapse, rheumatic tricuspid valve disease, endocarditis, connective tissues diseases or radiation therapy.

Symptoms

The symptoms of tricuspid regurgitation include those of right heart failure. Dyspnea on exertion is from reduced right ventricular cardiac output. Peripheral edema and right upper quadrant pain from hepatic congestion can occur.

Physical Examination

The murmur of tricuspid regurgitation is similar to that of mitral regurgitation. It is a high pitched, holosystolic murmur however it is best heard at the left lower sternal border and it radiates to the right lower sternal border.  The intensity significantly increases with inspiration due to increased venous return helping to distinguish it from mitral regurgitation. This inspiratory enhancement of the tricuspid regurgitation murmur is called "Carvallo's sign".

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Systolic hepatic pulsations may be felt in the right upper quadrant due to hepatic congestion. Peripheral pitting edema is frequently present. Large jugular V waves (Lancisi's sign) are seen during systole and represent the regurgitant volume. See the large jugular V waves in the video below in a patient with severe tricuspid regurgitation:

Diagnosis

The diagnosis is predominantly made on physical examination and echocardiography. The subjective size of the regurgitant jet is the main determinant on grading the TR as mild, moderate or severe.

Treatment

No specific medical therapy exists for tricuspid regurgitation. Diuretics to maintain a normal volume status can help to relieve dyspnea. Digoxin can increase right ventricular contractility, however has not been extensively researched for this indication.

Surgical repair or replacement is rarely required. The ACC/AHA Guidelines give the following indications to surgically repair the tricuspid valve:

1. Repair of the tricuspid valve in severe tricuspid regurgitation when mitral valve surgery is planned (class I, level of evidence B).
2. Tricuspid valve replacement or annuloplasty ring is reasonable to severe primary tricuspid regurgitation when right heart failure symptoms are present (class IIa, level of evidence C).
3. Tricuspid valve replacement is reasonable for severe tricuspid regurgitation due to organic valve disease that is not amenable to annuloplasty ring (class IIa, level of evidence C).
4. Tricuspid annuloplasty ring may be considered for moderate tricuspid regurgitation in patients undergoing mitral valve surgery when there is pulmonary hypertension or tricuspid annular dilatation (class IIb, level of evidence C).

By Steven Lome