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Tricuspid Regurgitation Symptoms and Treatment Guidelines

How serious is tricuspid regurgitation? Can mild tricuspid regurgitation get worse? Let’s find out about tricuspid regurgitation symptoms and treatment!

Tricuspid Regurgitation Definition

Tricuspid regurgitation meaning – What is tricuspid regurgitation? Tricuspid regurgitation is a condition where a valve does not close tightly enough. This problem makes blood flow back into the right upper heart chamber (atrium) when the right lower heart chamber (ventricle) contracts.

tricuspid regurgitation symptoms and treatment guidelines - tricuspid regurgitation murmur

Tricuspid Regurgitation Causes

What causes tricuspid regurgitation? What is the most common cause of tricuspid regurgitation? Most of the time, this condition is caused by the right ventricle getting bigger.

Tricuspid valve regurgitation usually happens when the RV gets bigger for any reason. As tricuspid regurgitation worsens, the RV gets bigger, which causes the chordal and papillary muscles to move and pull the valve open. This, in turn, makes the tricuspid regurgitation worse.

Also, the tricuspid annulus looks like the saddle of a horse. When the RV stops working, the annulus flattens and becomes elliptical. This makes the relationship between the leaflets and chordal attachments even more messed up. Most of the time, the RV geometry (function) is to blame for tricuspid regurgitation, not primary tricuspid valve disease. RV systolic hypertension from valvular or subvalvular pulmonary valve stenosis, pulmonary hypertension from any cause, severe pulmonary valve regurgitation, or cardiomyopathy can cause an enlarged, dilated RV.

The RV could also be hurt by a MI or be bigger than usual because of infiltrative diseases (RV dysplasia or sarcoidosis). Left heart failure is a common cause of RV dilation. Ebstein anomaly (when the septal and posterior leaflets, but not the anterior ones, move into the RV), tricuspid valve prolapse, carcinoid plaque formation, collagen disease inflammation, valvular tumours, or tricuspid endocarditis are all examples of problems that are built into the tricuspid valve. Another iatrogenic cause that is becoming more common is pacemaker lead valvular injury.

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Tricuspid Regurgitation Diagnosis

  • Usually happens when the right ventricle is overloaded with pressure or volume because of a lung or heart disease.
  • Tricuspid valve regurgitation from the placement of a pacemaker lead is becoming more common.
  • Echocardiography helps determine what’s wrong (low- or high-pressure tricuspid regurgitation).

Tricuspid Regurgitation Symptoms

Signs and symptoms of tricuspid regurgitation – What are some symptoms of tricuspid regurgitation?

The signs and symptoms of tricuspid regurgitation are the same as those of RV failure from any cause. Usually, the diagnosis can be made by looking carefully at the JVP. During ventricular systole, the JVP waveform should fall (the x descent). You can see when this decline starts by feeling the opposite carotid artery.

As tricuspid regurgitation worsens, the regurgitant wave fills up more and more of this x descent valley in the JVP until the x descent is gone, and a positive systolic waveform is seen in the JVP. A tricuspid regurgitation murmur may or may not be audible. It differs from mitral regurgitation by being on the left side of the chest and getting louder with breathing in (Carvallo sign).

A murmur may be accompanied by an S3 caused by the high flow from the RA back to the RV. Cyanosis may be present if the increased RA pressure stretches the atrial septum and opens a PFO or if there is a real ASD, like in about 50% of patients with Ebstein anomaly. When tricuspid regurgitation is very bad, it can cause liver enlargement, swelling, and ascites.

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Tricuspid Regurgitation Diagnostic Evaluation

The ECG usually doesn’t show anything specific, but atrial flutter or fibrillation is common. The chest x-ray may show an enlarged RA, a dilated azygos vein, or fluid in the pleural space. Finally, the echocardiogram is used to determine how bad the tricuspid regurgitation is.

Echocardiography/Doppler also shows the systolic pressure of the RV as well as the size and function of the RV. Due to the RV having too much volume, the interventricular septum may move strangely. Catheterization proves that the regurgitant wave is in the RA and that the pressure in the RA is high. If the PA or RV systolic pressure is less than 40 mm Hg, you should suspect that you have primary valvular tricuspid regurgitation.

At the same time as the right heart catheterization, a hepatic wedge pressure can be done on people with severe tricuspid regurgitation and ascites. Cirrhosis is likely to present if there is a big difference between the mean RA pressure and the mean hepatic wedge. The difference in pressure across the liver is usually less than 5 mm Hg. If the gradient is between 5 and 10 mm Hg, it is thought that the disease is mild. If the gradient is between 10 and 15 mm Hg, it is thought that the disease is moderate. If the gradient is over 15 mm Hg, it is thought that the disease is severe.

Tricuspid Regurgitation Treatment and Management Guidelines

Treatment of tricuspid regurgitation – What is the best treatment for tricuspid regurgitation?

Mild tricuspid regurgitation is common; most of the time, diuretics work well to treat it. When severe tricuspid regurgitation, bowel edema can make diuretics like furosemide less effective. This is why intravenous diuretics should be used first. When oral diuretics are added, torsemide or bumetanide is better. Aldosterone antagonists also play a role, especially if there are ascites. Adding a thiazide diuretic to a loop diuretic can sometimes make it work better.

Most tricuspid regurgitation is caused by something else, so getting rid of the cause of RV dysfunction is usually the only way to treat it for good. In secondary (functional) tricuspid regurgitation, surgery to replace the valve is rarely, if ever, needed until the cause of the RV dysfunction is fixed. If the problem is left heart disease, treating the left heart problem may lower pulmonary pressures, make the RV smaller, and fix the tricuspid regurgitation.

When the main and secondary causes of pulmonary hypertension are treated, the tricuspid regurgitation usually goes away. Guidelines say that tricuspid valve surgery should be considered when the tricuspid annular dilation at the end diastole is more than 4.0 cm and the patient has symptoms. Class I guidelines say that tricuspid annuloplasty should be done when there is a lot of tricuspid regurgitation and the mitral valve is being replaced or fixed for mitral regurgitation. Annuloplasty without putting in a prosthetic ring (DeVega annuloplasty) may also work to reduce the size of the tricuspid annulus. In some cases of tricuspid valve endocarditis, the valve leaflet can be fixed first. If the tricuspid valve has a problem that can’t be fixed, it should be replaced.

Most of the time, a bioprosthetic valve is used instead of a mechanical valve. This is because thrombosis of a mechanical valve is more likely if the INR is not stable. Bioprosthetic valves don’t need anticoagulation unless they come with atrial fibrillation or flutter. Transcatheter valve replacement has been shown to help with tricuspid regurgitation caused by bioprosthesis wear and tear. Percutaneous tricuspid valve replacement for native tricuspid regurgitation is said to work well.

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Should I worry about mild tricuspid regurgitation?

If you have moderate or severe tricuspid regurgitation, you should see a cardiologist at least once to determine if you need tests and treatment. A cardiologist needs to check on someone with severe tricuspid regurgitation regularly.

I hope you understand about tricuspid regurgitation symptoms and treatment guidelines.

About Micel Ortega

Dr. Micel Ortega, MD, PhD, is a highly respected medical practitioner with over 15 years of experience in the field of internal medicine. As a practicing physician, Dr. Micel has built a reputation for providing compassionate and evidence-based care to his patients. He specializes in the diagnosis and management of chronic conditions, including diabetes, hypertension, and heart disease. In addition to his clinical work, Dr. Micel has published extensively in top-tier medical journals on the latest advancements in internal medicine and has played an instrumental role in the development of innovative treatment options.

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