Station 3.5: Tricuspid incompetence

Question 1

Clinical signs

What are the clinical signs of Tricuspid incompetence?

Tricuspid incompetence

Examine this patient’s cardiovascular system. He has been complaining of abdominal discomfort

Answer 1

• Raised JVP with giant CV waves
• Thrill left sternal edge
• Auscultation
  ⚬ Pan-systolic murmur (PSM) loudest at the tricuspid area (lower left sternal edge) in inspiration.
  ⚬ Reverse split second heart sound due to rapid RV emptying.
  ⚬ Right ventricular rapid lling gives an S3.
• Pulsatile liver, ascites and peripheral oedema
• Endocarditis from IV drug abuse: needle marks
• Pulmonary hypertension: RV heave and loud P2
• Other valve lesions: rheumatic mitral stenosis

Question 2

Discussion - causes

What are the causes of Tricuspid incompetence?

Tricuspid incompetence

Examine this patient’s cardiovascular system. He has been complaining of abdominal discomfort

Answer 2

• Congenital: Ebstein’s anomaly (atrialization of the right ventricle and TR)
• Acquired:
  ⚬ Acute: infective endocarditis (IV drug user)
  ⚬ Chronic: functional (commonest), rheumatic and carcinoid syndrome

Question 3

Discussion - investigation

What investigations do you recommend for Tricuspid incompetence?

Tricuspid incompetence

Examine this patient’s cardiovascular system. He has been complaining of abdominal discomfort

Answer 3

• ECG: p‐pulmonale (large, peaked) and RVH
• CXR: double right heart border (enlarged right atrium)
• TTE: TR jet, RV dilatation

Question 4

Discussion - investigation

What investigations do you recommend for Tricuspid incompetence?

Tricuspid incompetence

Examine this patient’s cardiovascular system. He has been complaining of abdominal discomfort

Answer 4

• ECG: p‐pulmonale (large, peaked) and RVH
• CXR: double right heart border (enlarged right atrium)
• TTE: TR jet, RV dilatation

Question 5

Discussion - management

What management do you recommend for Tricuspid incompetence?

Tricuspid incompetence

Examine this patient’s cardiovascular system. He has been complaining of abdominal discomfort

Answer 5

• Medical: diuretics, β‐blockers, ACE inhibitors and support stockings for oedema
• Surgical: valve repair/annuloplasty if medical treatment fails