Tricuspid regurgitation - valvular 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 RV filling pressure can be associated with diastolic TR.
TR can be:
- primary (abnormal valve morphology)
- secondary (normal valve morphology).
How common is sub-acute TR?
Some degree of valvular regurgitation is a quite common accidental finding in colour Doppler imaging.
2D echocardiography has demonstrated:
- 50% - 60% of asymptomatic young adults exhibit mild tricuspid regurgitation.
- up to 15%, have moderate TR
What is the cause of TR?
valve morphology:
-
abnormal (primary)
- uncommon
- congenital aetiologies
- e.g. cleft valve in association w AV canal defect
- Ebstein’s anomaly
-
normal (secondary, functional)
- rheumatic valvulitis
- endocarditis
- scarring from carcinoid heart disease
- left-sided cardiac pathology in the form of:
- advanced mitral/ aortic/ LV myocardial disorders
What are some less common causes of TR?
normal (secondary, functional)
- rheumatoid arthritis
- Marfan’s syndrome
- pacemaker lead entrapment,
-
tricuspid valve prolapse
- (sometimes in association with myxomatous mitral valve disease)
-
following trauma
- (such as blunt force trauma or repeated endomyocardial biopsies)
- radiotherapy
-
toxin exposure
- (phentermine-fenfluramine [Phen-Fen] or methysergide)
What is the most clinically significant form of TR? And what is the most common cause of this?
secondary
cause:
left-sided cardiac pathology in the form of:
- advanced mitral/
- aortic/
- LV
myocardial disorders
What are the risk factors for TR?
- left-sided heart failure
-
rheumatic heart disease
- Rare cause of isolated TR
-
permanent pacemaker
- Risk factor for left-sided heart failure and subsequent TR.
-
dilated tricuspid annulus
- Any abnormality that impairs function of the annulus can result in valve regurgitation
- endocarditis
-
carcinoid heart disease
- –> scarring of the tricuspid valve
Name some weaker risk factors for TR
- pacemaker lead entrapment
- ischaemic cardiomyopathy
- constrictive pericarditis
- congenital heart disease
- toxins
- rheumatoid arthritis
- radiotherapy
- trauma
- Marfan’s syndrome
- tricuspid valve prolapse
What are the most common causes of tricuspid valve annulus dilation?
Tricuspid valve annulus dilation is most commonly secondary to:
- chronic heart failure
- left-sided rheumatic valvular heart disease
- pulmonary hypertension (less commonly)
Summarise the epidemiology of TR
It is most often found secondary to, or in association with:
- left-sided cardiac pathology in the form of advanced mitral, aortic, or left ventricular myocardial disorders.
In developed countries, the most commonly associated conditions include:
- ischaemic / degenerative mitral regurgitation
In developing countries, the association is with:
- rheumatic heart disease.
Rarely does TR present as an isolated disease process.
What are the presenting symptoms of TR?
-
Fatigue
- due to reduced CO
- + associated with LV and RV faillure
-
Dyspnoea
- due to reduced CO
- + associated with LV and RV faillure
-
Palpitations
- due to atrial arrhythmia (flutter, fibrillation)
-
Lower limb swelling
- due to reduced CO
- + associated with LV and RV faillure
????
- Headaches
- Nausea
- Anorexia
-
Epigastric pain
- made worse by exercise
- Jaundice
What are the signs of TR O/E?
inspection:
-
Raised JVP with giant V waves (which may oscillate the earlobes)
- due to incompetent tricuspid valve –> high right ventricular pressures –> transmission of high pressure into great veins
- ??? ~ cannon A waves
palpation:
- parasternal heave
Auscultation
- Pansystolic murmur -
- Loud P2 component of S2
- Where is the pansystolic murmur best heard?
- And which sign is associated with it?
- heard best at lower left sternal edge
- Louder on inspiration (Carvallo sign)
What may
a) chest examination
b) abdo examination
c) leg examination
show in TR?
a)
- Pleural effusion
- Causes of pulmonary hypertension
b)
- Palpable liver (tender, smooth and pulsatile)
- Ascites
c)
- pitting oedema
What are the primary investigations for ?TR
- transthoracic or transoesophageal echocardiogram
-
ECG
- ~atrial flutter/fibrillation
- ~previous MI
Bloods:
-
LFTs
- ~ normal/abnormal
-
serum urea and creatinine
- ~ normal/ elevated
- (due to renal abnormality)
-
FBC
- ~ anaemia
- ~ thrombocytopenia
imaging:
-
CXR
- Assesses for heart failure/enlargement
- ~ cardiomegaly
- ~ pleural or pericardial effusion
- ~ presence of pacemaker
What might a transthoracic echo show in TR?
- assessment of left and right heart ejection fraction/dilation
- valve morphology/function;
- evidence of pericardial disease,
- constrictive/restrictive physiology,
- may show regional wall motion abnormalities
What are some secondary possible investigations to consider for ?TR
