Tricuspid Regurgitation

Question 1

Definition

Answer 1

Backflow of blood from the right ventricle to the right atrium during systole

Question 2

Aetiology/Risk factors

Answer 2

· Congenital
o Ebstein’s anomaly (malpositioned tricuspid valve)
o Cleft valve in ostium primum

· Functional
o Consequence of right ventricular dilation (e.g. due to pulmonary hypertension)
o Valve prolapse

· Rheumatic Heart Disease

· Infective Endocarditis

· Other: carcinoid syndrome, trauma, cirrhosis, iatrogenic

Question 3

Epidemiology

Answer 3

· Differs based on cause

· Infective endocarditis is the MOST COMMON cause

Question 4

Presenting symptoms

Answer 4

· Fatigue
· Breathlessness
· Palpitations
· Headaches
· Nausea
· Anorexia
· Epigastric pain made worse by exercise
· Jaundice
· Lower limb swelling

Question 5

Signs on physical examination

Answer 5

· Pulse - irregularly irregular if AF

· Inspection
o Raised JVP with giant V waves (which may oscillate the earlobes)
o This is caused by transmission of high right ventricular pressures into the great veins
o Giant A waves may also be present

· Palpation - parasternal heave

· Auscultation
o Pansystolic murmur - heard best at lower left sternal edge
o Louder on inspiration (Carvallo sign)
o Loud P2 component of second heart sound

· Chest Examination may show signs of:
o Pleural effusion
o Causes of pulmonary hypertension

· Abdominal Examination may show:
o Palpable liver (tender, smooth and pulsatile)
o Ascites

· Legs - pitting oedema

Question 6

Investigations

Answer 6

· Bloods
o FBC
o LFT
o Cardiac enzymes
o Blood cultures

· ECG
o P pulmonale - due to right atrial hypertrophy

· CXR
o Right-sided enlargement of cardiac shadow

· Echocardiography
o Extent of regurgitation can be estimated using Doppler ultrasound
o May show valve prolapse and right ventricular dilation

· Right Heart Catheterisation
o Rarely necessary but may be useful for assessing pulmonary artery pressure