Tricuspid regurgitation Flashcards
What is tricuspid regurgitation?
Tricuspid regurgitation (TR) occurs when blood flows backwards through the tricuspid valve. In the vast majority of patients, this occurs during systole, but severely elevated right ventricular filling pressure can be associated with diastolic TR.
TR can be primary (abnormal valve morphology) or secondary (normal valve morphology).
What is the aetiology of tricuspid regurgitation?
- Functional overload - pulmonary hypertension, RV dilation
- Structural leaflet abnormalities - endocarditis, Ebstein anomaly
Ebstein anomaly = downward displacement of the congenitally malformed tricuspid cusp into the right ventricle
Describe the features of the tricuspid regurgitation murmur.
- PANSYSTOLIC murmur
- Heard better at lower left sternal edge (in the tricuspid area)
- Louder on inspiration - Carvallo’s sign
What are the risk factors for tricuspid regurgitation?
- LHF
- dilated tricuspid annulus
- rheumatic heart disease
- permanent pacemaker
- endocarditis
- carcinoid heart disease
- pacemaker lead entrapment
Other:
- ischaemic cardiomyopathy - ischaemia of RV is rare but can occur with LV infarction
- constrictive pericarditis - RF for LHF and so TR
- congenital heart disease - AV canal defect and Ebstein’s anomaly
- toxins, rheumatoid arthritis, radiotherapy, trauma (e.g. repeated endomyocardial biopsies)
- Marfan’s syndrome
- tricuspid valve prolapse
What are the symptoms of tricuspid regurgitation?
Symptoms:
- Associated with HF:
- Fatigue
- Dyspnoea
- Early satiety/dyspepsia/indigestion - gut congestion from reduced CO associated with RHF
- Palpitations - arrhythmia (flutter, fibrillation)
What are the signs of tricuspid regurgitation?
- Elevated JVP - giant v waves indicates pressure wave of RV systole transmitted through incompetent tricuspid valve
- Enlarged liver +/- pulsations if severe
- Peripheral oedema
- If severe, right jugular venous thrill may be palpable
- RV impulse at the left lower sternal border
- Irregular rhythm - AF/fibrillation
Auscultation:
- Pansystolic murmur louder on inspiration (Carvallo’s sign - helps distinguish from mitral regurgitation)
- Lower left parasternal murmur
What investigations would you do for tricuspid regurgitation?
- TTE - assesses R/L ejection fraction, valves, pericardial disease, constrictive/restrictive physiology, motion abnormalities
- ECG - may show atrial flutter/fibrillation; presence of previous myocardial infarction
- CXR - may show cardiomegaly, pleural or pericardial effusion, pacemaker presence
Other:
- LFTs - abnormal in chronic severe TR when ascites forms from chronic congestion/fibrosis
- FBC - anaemia (e.g., anaemia of chronic disease, renal failure), thrombocytopenia (e.g., due to liver failure and cirrhosis)
- Cardiac catheterisation - assesses pulmonary artery pressure; rarely necessary. Assess necessity of repair vs replacement of valve.
Describe the phonograms from the most common murmurs.
Summarise the common valvular pathologies (buzzwords).
Which of the following does not cause a systolic murmur?
- A.Atrial septal defect
- B.Ventricular septal defect
- C.Hypertrophic obstructive cardiomyopathy (HOCM)
- D.Aortic regurgitation
- E.None of the above
D
You perform a cardiovascular examination on an elderly gentleman who reports episodes of collapsing and often wakes up short of breath at night. Upon auscultation you discover an ejection systolic murmur, which radiates to the carotids. Which is the most likely valvular pathology?
- A.Aortic stenosis
- B.Aortic regurgitation
- C.Mitral regurgitation
- D.Tricuspid regurgitation
- E.Mitral stenosis
A
Mitral regurgitation - Pan-systolic –> radiates to the axilla
Aortic Stenosis - mid-systolic –> radiates to the carotids
A 53-year-old woman with Atrial Fibrillation is reviewed by her cardiologists. On inspection the patients cheeks appear quite flushed. Auscultation reveals a very loud S1 and a mid diastolic murmur. Which is the most likely valvular pathology?
- a)Mitral stenosis
- b)Graham Steele
- c)Mitral regurgitation
- d)Aortic regurgitation
- e)Austin Flint
Mitral stenosis A
- Graham Steell murmur is associated with pulmonary regurgitation
- It is a high pitched early diastolic murmur
- Heard best at the left sternal edge at full inspiration
49-year-old women presents with 3 month history of increasing SOB on exertion. She has no chest pain, cough or ankle swelling. On examination: BP 158/61 and there are crackles at the bases of both lungs. On auscultation you hear a diastolic decrescendo murmur loudest at the left sternal edge.
Which is the most likely valvular pathology?
- a)Aortic regurgitation
- b)Aortic stenosis
- c)Mitral regurgitation
- d)Mitral stenosis
- e)Tricuspid regurgitation
LHF causes pulmonary oedema
LH so aortic/mitral
A aortic regurgitation - diastolic decrescendo murmur loudest at the left sternal edge.
Which sign is commonly associated with a valvular condition where the murmur is heard louder during expiration, and softer during the Valsalva manoeuvre, and typically radiated to the carotid?
- a)Water hammer (collapsing pulse)
- b)Flushed cheek (malar rash)
- c)Displaced apex beat
- d)Slow-rising pulse
- e)Subcutaneous nodules
Aortic stenosis so D
