Right heart valve disease (CV) Flashcards
What is tricuspid stenosis defined by?
Rare condition defined by an abnormally elevated pressure gradient across the tricuspid valve during diastolic filling of the RV
What does tricuspid stenosis rarely occur in the absence of?
Associated rheumatic mitral and/or aortic disease
What is a cause of tricuspid stenosis?
Rheumatic fever - which almost always occurs with mitral or aortic valve disease
What is tricuspid regurgitation?
When blood flows backwards through the tricuspid valve - majority during systole, but severely elevated RV filling pressure can be associated with diastolic TR
Who can mild/moderate tricuspid regurgitation affect?
Mild/moderate tricuspid regurgitation without abnormal valve anatomy, ventricular function, or pulmonary artery pressure is not necessarily abnormal and is estimated to be present in >50% of asymptomatic young adults (incidental findings)
What is the most important form of tricuspid regurgitation clinically?
Secondary to left-sided cardiac disease, with tricuspid annular dilation
How can tricuspid regurgitation be classified? (2)
- primary TR - abnormal valve morphology
- secondary TR - normal valve morphology
What are some causes of tricuspid regurgitation? (6)
- functional: RV dilatation e.g. due to pulmonary hypertension
- rheumatic fever (recent sore throat, chorea, polyarthralgia, erythema marginatum)
- infective endocarditis in IVDU
- congenital (e.g. Ebstein’s anomaly - malpositioned tricuspid valve)
- drugs e.g. ergot-derived dopamine agonists
- other: carcinoid syndrome, trauma, cirrhosis, iatrogenic
What are the features of rheumatic fever (valve disease)? (4)
- recent sore throat
- chorea - sudden uncontrollable jerky movements of arms, legs, facial muscles
- polyarthralgia - pain in multiple joints
- erythema marginatum
What is pulmonary stenosis?
Obstruction of blood flow from RV into pulmonary bed, resulting in a pressure gradient >10mmHg across the pulmonary valve during systole
What is a cause of pulmonary stenosis?
Usually congenital e.g. Tetralogy of Fallot
Associated with carcinoid heart disease (Hedinger syndrome)
What is pulmonary regurgitation?
Leakage of blood from pulmonary artery back into RV - rare and infrequently symptomatic
What causes pulmonary regurgitation?
Any cause of pulmonary hypertension / increased pulmonary artery pressure
What are the clinical features of tricuspid stenosis? (2)
- fatigue
- dyspnoea
What might you find on examination of tricuspid stenosis?
- elevated JVP with prominent a-wave + jugular pulsations
- abdominal swelling and discomfort
- cyanosis or hypoxaemia
- ascites, hepatomegaly, oedema
- mid-diastolic murmur at left lower sternal border, louder during inspiration
What murmur would you hear in tricuspid stenosis?
Mid-diastolic murmur - at left lower sternal border, louder during inspiration
What are the clinical features of tricuspid regurgitation? (10)
- fatigue
- dyspnoea/breathlessness
- lower limb oedema
- palpitations
- headaches
- nausea
- anorexia
- epigastric pain - worse on exercise
- jaundice
- ascites
What might you see on examination in tricuspid regurgitation?
- pulse - irregularly irregular if AF
- inspection - raised JVP with giant v-waves (which may oscillate earlobes) - caused by transmission of high RV pressures into great veins
- palpation - parasternal heave
- auscultation - pansystolic murmur (best heard at lower left sternal edge on inspiration - Carvallo sign) + loud P2 component of second heart sound
- chest examination - signs of pleural effusion, causes of pulmonary hypertension
- abdominal examination - palpable liver (tender, smooth, pulsatile), ascites, jaundice
- legs - pitting oedema
What murmur would you hear in tricuspid regurgitation?
Pansystolic murmur - left lower sternal edge (4th intercostal left parasternal region) on inspiration
What are the clinical features of pulmonary stenosis? (6)
- fatigue
- dyspnoea
- chest pain
- ascites
- oedema
- ejection systolic murmur
What murmur would you hear in pulmonary stenosis?
Ejection-systolic murmur with or without a systolic click - loudest over left upper sternal border
Severe/critical PS - long and harsh murmur peaking later in systole
Critical PS - may be soft due to poor cardiac output
What murmur would you hear in pulmonary regurgitation?
Early diastolic murmur (low-pitched decrescendo along left sternal border)
What is the RILE acronym for heart murmurs?
- Right-sided murmurs louder on Inspiration
- Left-sided murmurs louder on Expiration
How can we remember where to auscultate different murmurs?
A Place To Meet 22:45
- Aortic - right 2nd ICS sternal border
- Pulmonary - left 2nd ICS sternal border
- Tricuspid - left 4th/5th ICS sternal border
- Mitral - left 5th ICS, MCL
