Tricuspid regurgitation

Question 1

define tricuspid regurgitation?

Answer 1

backflow of blood from the right ventricle to the right atrium during systole ( but when severely elevated RV filling pressure, it can occur during diastole)

Question 2

outline the causes/ risk factors for tricuspid regurgitation?

Answer 2

Congenital

• Ebstein’s anomaly (malpositioned tricuspid valve
• Cleft valve in ostium primum

Functional

• Consequence of right ventricular dilation (e.g. due to pulmonary hypertension)
• Valve prolapse
• Rheumatic Heart Disease
• Marfan’s syndrome
• Pacemaker lead entrapment
• Infective Endocarditis (IV drug user) - first valve encountered by bacteria after venous injections
• Other: carcinoid syndrome, trauma, cirrhosis, iatrogenic Drugs e.g. ergot-derived dopamine agonists, fenfluramine

Question 3

summarise the epidemiology of tricuspid regurgitation?

Answer 3

differs based on cause infective endocarditis in MOST COMMON cause

Question 4

What are the presenting symptoms of tricuspid regurgitation?

Answer 4

fatigue breathlessness palpitations headaches nausea anorexia epigastric pain made worse by exercise jaundice lower limb swelling ascites oedema

Question 5

what are the signs of tricuspid regurgitation

Answer 5

Pulse

• irregularly irregular if AF

Inspection

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

Palpation - parasternal heave

Auscultation

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

Chest Examination may show signs of:

• Pleural effusion
• pulmonary hypertension

Abdominal Examination may show:

• Palpable liver (tender, smooth and pulsatile) - if severe
• Ascites causing abdo distention
• jaundice
• Gut congestion due to reduced CO and R-sided HF causing early satiety, dyspepsia or indigestion Legs - pitting oedema

Question 6

what are the appropriate investigation for tricuspid regurgitation?

Answer 6

bloods

FBC – related to renal and liver abnormality (e.g. anemia/ thrombocytopenia)

LFT – if severe this may be abnormal

Cardiac enzymes

U&Es – if renal abnormality is present

Blood cultures

ECG

Atrial flutter/ fib may be seen

P pulmonale - due to right atrial hypertrophy

CXR

Right-sided enlargement of cardiac shadow

Echocardiography

Extent of regurgitation can be estimated using Doppler ultrasound

May show valve prolapse and right ventricular dilation

Right Heart Catheterisation

Rarely necessary but may be useful for assessing pulmonary artery pressure and deciding whether to go for valve repair or replacement