subject: Tricuspid regurgitation and its clinical features [print this page] Tricuspid regurgitation most commonly arises as a resultof dilatation of the valve ring secondary to right heartfailure with pulmonary hypertension. Less common causesare actual rheumatic involvement of the tricuspid valveleaflets producing 'organic tricuspid disease', and right sided endocarditis, which is rare in anyone other than intravenous drug addicts. Floppy tricuspid valve may be associated with floppy mitral valve, and some congenital heart disease is associated with tricuspid regurgitationeither as a primary phenomenon or secondary to right heart enlargement (e.g. atrial septal defect). Endomyocardial fibrosis, a disease occurring in the tropics, especially Africa, causes mitral and tricuspid regurgitation.Doppler ultrasound has shown that a right-sided cardiacenlargement in rheumatic heart disease is almost invariablyassociated with a regurgitant jet through the tricuspidvalve, very often in the absence of any physical signs.Similarly, it may be the cause of an 'innocent systolicmurmur'.
Clinical features
Pathophysiology and symptoms The leakage of a small percentage of the right ventricular stroke volume is easily accommodated by the right atrium.As the volume of regurgitation increases, there is increasing enlargement of the right atrium and right ventricle,and the movement of the interventricular septum becomes dominated by the right ventricle and so 'paradoxical'. The large systolic pressure pulse in the right atrium leads tostagnation and, eventually, reversal of blood flow in the great veins; the liver becomes distended and pulsatile . The high hepatic venous pressure leads to cardiaccirrhosis, and this may occasionally lead to secondary portal hypertension and splenomegaly.The poor venous return, high venous pressures and poor hepatic function are associated, in most patients, with adegree of cardiac cachexia, poor wound healing and difficultieswith haemostasis.Tricuspid regurgitation due to disease of the valve ismuch better tolerated, as the regurgitation is at a muchlower pressure than when it is secondary to pulmonary hypertension.The principal symptoms are those of right heart failure,with low cardiac output, fatigue, oedema and pain fromhepatic congestion which may arise on exercise - so-called'hepatic angina', i.e. epigastric or right-sided subcostal painarising on exercise and gradually (more gradually than'true' angina) disappearing with cessation of exercise.
Signs
The patient may have AF and is often slightly jaundiced.In moderate to severe cases there is a highly pulsatilejugular vein with a large v wave and rapid y descent. Theheight of the v wave peak may be as much as 15cm abovethe sternal angle, and in these circumstances the jugular vein is palpably pulsatile and can be confused with an arterialpulse. The right ventricle is very active and gives riseto a right parasternal impulse. A pansystolic murmur isheard at the left sternal edge, or even at the cardiac apex,which may be formed by the right ventricle under these circumstances. The murmur is often lower in pitch than amitral murmur. There can be a right ventricular third heartsound.Abdominal examination reveals a pulsatile liver, whichis often visible but is best felt bimanually.
Management
As tricuspid regurgitation is often secondary to pulmonary hypertension, the treatment is frequently that of the underlying cause. Bed rest and diuretics will be effective in manycases, with the murmur and pulsatile jugular veins disappearing.Intravenous diuretics may be required, as the oral drugs may be poorly absorbed. Organic tricuspid valve disease may require surgical treatment by replacement or annuloplasty at the same time as other cardiac surgery.
