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tricuspid regurgitation (TR)

Etiology: 1) dilatation of right ventricle resulting from a) mitral valve disease b) biventricular infarction c) pulmonary hypertension d) pulmonary valve stenosis 2) congenital heart disease 3) permanent pacemaker or implantable cardioverter-defibrillator leads [4] 4) tricuspid valve prolapse a) trauma b) endocarditis 1] fungal 2] Staphylococcal in drug addicts 5) pulmonary hypertension can cause regurgitation of a structurally normal tricuspid valve [2] 6) carcinoid syndrome 7) pharmaceutical agents: fen-phen Clinical manifestations: - tricuspid regurgitation is usually functional and asymptomatic. - jugular venous distension: - merged & prominent v wave & c wave (Lancisi sign) - increases with Valsalva, then decreases within 2-3 seconds - prominent right ventricular impulse below sternum - pansystolic murmur at the left lower sternal border - murmur increases during inspiration - right-sided 3rd heart sound may be heard - peripheral edema - hepatomegaly, pusatile, enlarged liver - ascites possible Management: - difficult to treat - loop diuretics & aldosterone antagonists first line therapy prior to surgery [2] - surgery - indications - severe tricuspid regurgitation with symptoms & evidence of right ventricular enlargement or right heart failure [2] - severe tricuspid regurgitation at the time of surgery for left sided valve - endocarditis - tricuspid valve removal - patients may tolerate complete valve removal for years - pulmonary hypertension (not mentioned in MKSAP17) - often performed in conjunction with other cardiac surgery - contraindications - does not improve survival in isolated tricuspid regurgitation [5] - procedures - removal of ICD lead passing through valve is risky [2] - tricuspid valve repair if anatomy is favorable - tricuspid valve replacement - bioprosthetic or mechanical valve - bioprosthetic valve preferred [2] - bioprosthetic tricuspid valves do not degenerate as fast as left-sided valves - tricuspid valve removal (endocarditis) - percutaneous transcatheter-based repair [6,7]

Related

jugular venous distension (JVD) JVP v-wave tricuspid valve

General

tricuspid valve disease

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 45
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  3. Bruce CJ, Connolly HM. Right-sided valve disease deserves a little more respect. Circulation. 2009 May 26;119(20):2726-34 PMID: 19470901
  4. Lin G, Nishimura RA, Connolly HM et al Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol. 2005 May 17;45(10):1672-5. PMID: 15893186 Free Article
  5. Axtell AL, Bhambhani V, Moonsamy P et al. Surgery does not improve survival in patients with isolated severe tricuspid regurgitation. J Am Coll Cardiol 2019 Aug 13; 74:715-725. PMID: 31071413 - O'Gara PT Gillinov M, Rodes-Cabau J. Surgery for isolated tricuspid regurgitation: Limitations of observational analyses. J Am Coll Cardiol 2019 Aug 13; 74:726-728 PMID: 31395121
  6. Nickenig G et al. Transcatheter edge-to-edge repair for reduction of tricuspid regurgitation: 6-month outcomes of the TRILUMINATE single-arm study. Lancet 2019 Nov 30; 394:2002 PMID: 31708188 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32600-5/fulltext
  7. Taramasso M, Benfari G, van der Bijl P et al. Transcatheter versus medical treatment of patients with symptomatic severe tricuspid regurgitation. J Am Coll Cardiol 2019 Dec 17; 74:2998 PMID: 31568868 https://www.sciencedirect.com/science/article/pii/S0735109719377393
  8. Ali MA, Colquhoun M Lancisi sign: Gian C-V Waves in Tricuspid Regurgitation. Mayo Clin Proc 2020 95(12):2592-93 PMID: 33276831 https://www.mayoclinicproceedings.org/article/S0025-6196(20)30992-7/fulltext