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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 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: 1) jugular venous distension: - merged & prominent v wave & c wave (Lancisi sign) - increases with Valsalva, then decreases within 2-3 seconds 2) prominent right ventricular impulse below sternum 3) pansystolic murmur at the left lower sternal border - murmur increases during inspiration 4) right-sided 3rd heart sound may be heard 5) peripheral edema 6) hepatomegaly, pusatile, enlarged liver - ascites possible Management: - difficult to treat - loop diuretics & aldosterone antagonists [2] - surgery - does not improve survival in isolated tricuspid regurgitation [5] - procedures - 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] - indications - pulmonary hypertension (not mentioned in MKSAP17) - 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 - often performed in conjunction with other cardiac surgery [2]

Related

jugular venous distension (JVD) JVP v-wave mitral 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.
  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