Tricuspid regurgitation

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Tricuspid regurgitation
ICD-10 I07.1, I36.1
ICD-9 397.0
DiseasesDB 13348
eMedicine med/2314 
MeSH D014262

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Overview

Causes

Although congenital causes of tricuspid insufficiency exist, most cases are due to dilation of the right ventricle. Such dilation leads to derangement of the normal anatomy and mechanics of the tricuspid valve and the muscles governing its proper function. The result is incompetence of the tricuspid valve. Common causes of right ventricular dilation include left heart failure, pulmonary hypertension, and right ventricular infarction. One notable exception to right ventricular dilation as a cause of tricuspid insufficiency occurs in right-sided endocarditis (i.e. infection affecting the right side of the heart). In that case, there is direct damage to the tricuspid valve as as a result of infection.

Diagnosis

Symptoms

Tricuspid insufficiency may be asymptomatic, especially if right ventricular function is well preserved. Conversely, edema, vague upper abdominal discomfort (from a congested liver), and fatigue (due to diminished cardiac output) can all be present to some degree.

Physical examination

On examination, the jugular venous pressure is usually elevated, and 'CV' waves can be seen. The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency). Peripheral edema is often found. In severe cases, there may be ascites and even cirrhosis (so-called 'cardiac cirrhosis).

Tricuspid insufficiency may lead to the presence of a pansystolic heart murmur. Such a murmur is usually of low frequency and best heard low on the left sternal border. It tends to increase with inspiration. However, the murmur may be inaudible reflecting the relatively low pressures in the right side of the heart. A third heart sound may also be present.

Echocardiography

The diagnosis is usually confirmed on echocardiography if a pulsatile liver and/or the presence of prominent CV waves in the jugular pulse is noted on physical examination.

Therapy

In most cases, surgery is not indicated since the root problem lies with a dilated or damaged right ventricle. Medical therapy with diuretics is the mainstay of treatment. Unfortunately, this can lead to volume depletion and decreased cardiac output. Indeed, one must often accept a certain degree of symptomatic tricuspid insufficiency in order to prevent a decrease in cardiac output. Treatment with medicines to reduce cardiac afterload may also be of benefit but a similar risk of depressed cardiac output applies.

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