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Tricuspid Valve Insufficiency

Tricuspid valve insufficiency, or tricuspid regurgitation, is a condition that involves a jet of blood pathologically leaking backward from the right ventricle into the right atrium during the systolic phase of the cardiac cycle.


Presentation

Tricuspid valve insufficiency is widely classified into two categories: the primary type, which occurs due to congenital or acquired structural abnormalities of the tricuspid valve, and secondary tricuspid valve insufficiency, which is caused by other underlying heart pathologies, such as right ventricular dilatation, trauma, rheumatic heart disease, or infective endocarditis [1] [2] [3].

Tricuspid valve insufficiency may be asymptomatic in patients with moderate, or even severe, stage of the disease. This can account for its frequent detection during diagnostic procedures carried out for other reasons, such as an assessment of left-side cardiac disease [4]. When symptomatology is experienced by the patient, an appearance of the symptoms most commonly reported depend on whether or not tricuspid valve insufficiency is directly related to left ventricular dysfunction. These may generally include:

Rales
  • The physical examination may also reveal jaundice, peripheral edema, ascites, weak peripheral pulse, pulmonary rales, and an S3 or S4 gallop.[symptoma.com]
Fatigue
  • These may generally include: Peripheral edema Fatigue and weakness Hepatomegaly (congestive) Ascites Dyspnea upon exertion, orthopnea, and paroxysmal nocturnal dyspnea Decreased ability to perform physical exercise Decreased urine production Angina (rare[symptoma.com]
  • Tricuspid valve insufficiency usually produces such vague symptoms, as general weakness and fatigue . As the conditions worsens, a person experiences pain in the upper right part of the abdomen, caused by a congested and enlarged liver.[medical-dictionary.thefreedictionary.com]
  • Symptoms of tricuspid regurgitation include: abdominal swelling decreased urine output foot and ankle swelling general weakness an irregular heart rhythm swelling in the body pulsing in your neck vein unexplained fatigue There are three main causes of[healthline.com]
  • The clinical picture of tricuspid valve insufficiency For tricuspid regurgitation initial symptoms are fatigue and weakness secondary to decrease in cardiac output.[heartupdate.com]
  • The older children and adults received the following complaints: severe fatigue; shortness of breath; blueness of the skin. In 25% of patients have rapid pulse, dizziness and pain in the chest or neck.[vascular.vsebolezni.com]
Heart Disease
  • Stenosis - when the valve doesn't open enough and blocks blood flow Valve problems can be present at birth or caused by infections, heart attacks, or heart disease or damage.[icdlist.com]
  • disease, or infective endocarditis.[symptoma.com]
  • The ICD code I361 is used to code Tricuspid insufficiency Tricuspid insufficiency (TI), a valvular heart disease also called tricuspid regurgitation (TR), refers to the failure of the heart's tricuspid valve to close properly during systole.[icd.codes]
  • Tricuspid insufficiency ( TI ), a valvular heart disease also called tricuspid regurgitation ( TR ), refers to the failure of the heart's tricuspid valve to close properly during systole .[en.wikipedia.org]
Heart Murmur
  • The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope. But many people have heart murmurs without having a problem.[icdlist.com]
  • Diagnosis A leaky valve can be heard with a stethoscope; the sound is called a heart murmur. Additional support for diagnosing tricuspid valve insufficiency comes from a medical history, physical exam, and chest x ray .[medical-dictionary.thefreedictionary.com]
  • Your doctor will also listen to your heart for the presence of a heart murmur. This abnormal heart sound can indicate that blood is flowing backward from the heart valve. After listening to your heart, your doctor may order diagnostic tests.[healthline.com]
  • Heart murmurs are frequently absent and blood cultures may be negative. Annular abscesses are not uncommon.[emedicine.medscape.com]
Mitral Valve Prolapse
  • If they don't, you could have Regurgitation - when blood leaks back through the valve in the wrong direction Mitral valve prolapse - when one of the valves, the mitral valve, has "floppy" flaps and doesn't close tightly.[icdlist.com]
  • CODING SNAPSHOT PREOPERATIVE DIAGNOSIS: Severe Mitral Valve Prolapse and Regurgitation OPERATION: Mitral Valve Repair INDICATIONS FOR SURGERY: A 50-year-old woman with a long history of mitral valve prolapse is basically asymptomatic and has severe regurgitation[aapc.com]
  • Leaky Heart Valve and Mitral Regurgitation Causes of a leaky mitral valve include: Mitral valve prolapse (an improper closing of the valve) An enlarged heart , called cardiomyopathy , due to hypertension , coronary artery disease , or another cause Endocarditis[webmd.com]
  • (valve) prolapse I342Nonrheumatic mitral (valve) stenosis I348Other nonrheumatic mitral valve disorders I349Nonrheumatic mitral valve disorder, unspecified I350Nonrheumatic aortic (valve) stenosis I351Nonrheumatic aortic (valve) insufficiency I352Nonrheumatic[cms.gov]
  • Valve Prolapse AORTIC AND VASCULAR DISEASE Aortic Stenosis: Rheumatic and Nonrheumatic Causes Aortic Stenosis: Rheumatic and Nonrheumatic Causes (Continued) Aortic Regurgitation: Pathology Aortic Regurgitation: Pathology (Continued) Transcutaneous Aortic[euro-libris.ro]
Pansystolic Murmur
  • Common findings include distended jugular veins, hepatomegaly, pansystolic murmur auscultated in the parasternal area at the 4th intercostal space.[symptoma.com]
  • Listener can observe the emergence of noise 3 emphasized inspiration and Valsalva maneuver decreased, P2 increased in case of occurrence of pulmonary hypertension 12 and parasternal pansystolic murmur that increases in inspiration.[heartupdate.com]
  • Cardiac murmurs are often present: A pansystolic murmur, which may signify blood flow through the ventricular septal defect.[patient.info]
Systolic Murmur
  • Phonocardiogram (shows a systolic murmur). Echo (the main method shows the deformation and thinning of the flaps, the formation of new structures, etc.). Spiral computed tomography (provides an informative picture of the heart).[vascular.vsebolezni.com]
  • Tricuspid valve prolapse may present with a midsystolic click and a late systolic murmur, most prominent at the lower left sternal border.[patient.info]
Hepatomegaly
  • Finally, laboratory tests may reveal hyperbilirubinemia and increased liver transaminase levels due to congestive hepatomegaly.[symptoma.com]
  • His recent chest radiograph revealed increased cardiothoracic ratio and ultrasound abdomen showed hepatomegaly.[omicsonline.org]
  • Blood flow into the pulmonary circulation is impaired and is accompanied by peripheral oedema and hepatomegaly.[patient.info]
  • They may also present with signs of elevated right atrial pressure, such as peripheral oedema and abdominal fullness, congestive hepatomegaly and ascites.[heart.bmj.com]
Pulsatile Liver
  • Right heart failure leads to ascites, hepatosplenomegaly, pulsatile liver, peripheral edema and pleural overflow. In advanced stages patients are cachectic and cyanotic. Atrial fibrillation is common in right atrial dilatation.[heartupdate.com]
  • Fatigue, weakness, shortness of breath, jugular vein distension, ascites, hepato-splenomegaly, pulsatile liver, pleural effusions and peripheral oedema may be present.[escardio.org]
Neglect
  • It is concluded that endomyocardial biopsy, although it is the most useful tool for detection of rejection, should be used with caution with regard to anatomical structures and the risk of damage to the tricuspid valve must not be neglected.[ncbi.nlm.nih.gov]

Workup

Diagnosing tricuspid valve insufficiency involves an extensive workup, including a consistent physical examination, laboratory tests, electrocardiography, echocardiography, and chest radiographs.

A thorough physical examination is the first step towards achieving diagnostic success. Common findings include distended jugular veins, hepatomegaly, pansystolic murmur auscultated in the parasternal area at the 4th intercostal space. Inspiration leads to a louder murmur and performing a Valsalva maneuver typically reduces its intensity. The physical examination may also reveal jaundice, peripheral edema, ascites, weak peripheral pulse, pulmonary rales, and an S3 or S4 gallop.

The imaging technique predominantly relied upon to diagnose tricuspid valve insufficiency is the transthoracic echocardiography (TTE), more specifically, the color flow Doppler echocardiography. This imaging modality allows for a comprehensive evaluation of the heart and can differentiate between primary and secondary tricuspid valve insufficiency [1]. It can help to determine the severity of the condition and calculate annular diameters. Some of the echocardiographic criteria for the determination of a severe tricuspid valve insufficiency are [6]:

  • A regurgitant flow greater than 30% of the area of the right atrium
  • Width of the vena contracta greater than 7mm
  • A reversal of systolic flow in hepatic vein flow
  • Right ventricular dilatation (RV eccentricity index greater than 2)

Echocardiographic findings should always be interpreted in accordance with the phase of the respiratory cycle in which the image was taken. In tricuspid valve insufficiency inspiration augments the size of the right ventricle, alter its morphology, lead to tricuspid annular dilatation, and a deficit of the leaflet coaptation [7].

A transesophageal echocardiography is solely carried out in cases where the cause of tricuspid valve insufficiency cannot be pinpointed by a standard color flow transthoracic echocardiography [6].

Cardiovascular magnetic resonance (CMR) is another imaging modality that can be used to assess a potential tricuspid valve insufficiency and can aid in the calculation of the regurgitant fraction and volume [8].

With regard to the contribution of a chest radiography to the diagnosis, it may illustrate cardiomegaly, pleural effusions, and elevation of the diaphragm due to ascites.

Finally, laboratory tests may reveal hyperbilirubinemia and increased liver transaminase levels due to congestive hepatomegaly.

Prominent A-Wave
  • Physical examination findings include jugular venous distension with a prominent v-wave, hepatomegaly and, rarely, a soft systolic regurgitant murmur can be heard that increases during inspiration owing to the increased venous return.[heart.bmj.com]
Prominent V-Waves
  • Physical examination findings include jugular venous distension with a prominent v-wave, hepatomegaly and, rarely, a soft systolic regurgitant murmur can be heard that increases during inspiration owing to the increased venous return.[heart.bmj.com]

Treatment

  • He was discharged home with slight tricuspid regurgitation, without signs of hemodynamic decompensation, and required no further treatment.[ncbi.nlm.nih.gov]
  • This study assesses the results of the 'clover technique' (suturing together the middle point of the free edges of the tricuspid leaflets) for the treatment of tricuspid regurgitation (TR) due to severe prolapse or tethering.[ncbi.nlm.nih.gov]
  • The rare congenital anomaly of pulmonary valve stenosis and massive tricuspid valve insufficiency with intact ventricular septum is a lethal condition without reported survival after attempted treatment.[ncbi.nlm.nih.gov]
  • The treatment during the acute phase consisted of volume loading and positive inotropic agents. Seven days later the clinical signs of tricuspid valve insufficiency and concomitant right heart failure had disappeared.[ncbi.nlm.nih.gov]
  • To summarize the experience in the diagnosis and treatment of TTVI, we have analyzed the clinical data of 3 patients with TTVI who were admitted to the department of cardiac surgery of our hospital between April 1997 to April 2002.[ncbi.nlm.nih.gov]

Prognosis

  • When focusing on TI to improve the prognosis of patients with pre-capillary PH, both PASP and RV dimensions should be taken into consideration.[ncbi.nlm.nih.gov]
  • Prognosis Tricuspid valve insufficiency is not usually considered to be serious. If it is the result of other cardiopulmonary disease, the extent of those conditions effect the prognosis.[medical-dictionary.thefreedictionary.com]
  • Prognosis Prognosis is generally good but dependent on the prognosis of the underlying disease, associated other heart abnormalities and associated arrhythmias. Tricuspid regurgitation [ 1 ] The incidence of TR is less than 1%.[patient.info]
  • Surgical valve repair or valve replacement usually cures the condition, but those with untreated, severe tricuspid regurgitation may face a poor prognosis, either from the valve disease itself or because of the complications from the underlying condition[heart.org]
  • Prognosis for these patients depends upon the degree of apical displacement of the tricuspid annulus and the severity of the regurgitation. [3] The incidence of tricuspid valve prolapse (floppy tricuspid valve) varies from 0.3-3.2%.[emedicine.medscape.com]

Etiology

  • In persons with an anatomically normal tricuspid valve, a common etiology of tricuspid regurgitation is dilatation of the RV cavity.[emedicine.medscape.com]
  • Regardless of the underlying etiology, ventricular dilatation exacerbates tricuspid insufficiency through annular dilatation. These changes in compliance are easily seen in tracings of the RA and RV end-diastolic pressures.[ispub.com]
  • Anomalies of the Aortic Arch System: Coarctation of Aorta Endocardial Fibroelastosis and Glycogen Storage Disease Section 6 - Acquired Heart Disease ISCHEMIC HEART DISEASE Structure of Coronary Arteries Pathogenesis of Atherosclerosis Risk Factors in Etiology[euro-libris.ro]

Pathophysiology

  • Tricuspid valve anomalies are part of the pathological spectrum in various congenital heart diseases, including Ebstein anomaly and tricuspid valve dysplasia, with different pathophysiology and clinical implications.[books.google.com]
  • "Right Ventricular Function in Cardiovascular Disease, Part II Pathophysiology, Clinical Importance, and Management of Right Ventricular Failure" . Circulation . 117 (13): 1717–1731. doi : 10.1161/CIRCULATIONAHA.107.653584 . ISSN 0009-7322 .[en.wikipedia.org]
  • Principal Sites of Embolism from Left Artial Thrombosis Rheumatic Heart Disease: Mitral Stenosis: Thromboembolic Complications: Mitral Balloon Valvuloplasty Rheumatic Heart Disease: Mitral Regurgitation Rheumatic Heart Disease: Mitral Regurgitation: Pathophysiology[euro-libris.ro]
  • The pathophysiology of secondary TR is related to RV and annular dilatation or tethering (even with little annular dilatation) 12 in connection to pulmonary hypertension.[heart.bmj.com]
  • ., Pathophysiology of tricuspid regurgitation: quantitative Doppler echocardiographic assessment of respiratory dependence, Circulation, 2010;122(15):1505–13.[icrjournal.com]

Prevention

  • A good functional result can be achieved years after onset of traumatic valve insufficiency, but early diagnosis and surgical treatment increases the feasibility of tricuspid valve repair rather than replacement, and also prevents progressive deterioration[ncbi.nlm.nih.gov]
  • Prevention In general, tricuspid valve insufficiency cannot be prevented. Resources Organizations American Heart Association. 7320 Greenville Ave., Dallas, TX 75231-4596. (214) 373-6300 or (800) 242-8721. [email protected] .[medical-dictionary.thefreedictionary.com]
  • To control the intake of salt and fluids to prevent edema. To give up Smoking and alcohol. To avoid dynamic and excessive exercise. To prevent hypothermia. To deal with stress.[vascular.vsebolezni.com]
  • […] of traumatic tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve insufficiency, earlier diagnosis and surgical treatment should increase the feasibility of tricuspid valve repair, prevent[ncbi.nlm.nih.gov]
  • Haverich A, Albes JM, Fahrenkamp G, Schäfers H-J, Wahlers T, Heublein B (1991) Intraoperative echocardiography to detect and prevent tricuspid valve regurgitation after heart transplantation.[link.springer.com]

References

Article

  1. Maeba S, Taguchi T, Midorikawa H, Kanno M, Suedac T. Four-dimensional geometric assessment of tricuspid annulus movement in early functional tricuspid regurgitation patients indicates decreased longitudinal flexibility. Interact Cardiovasc Thorac Surg. 2013;16(6):743–749.
  2. Luo GH, Ma WG, Sun HS, et al. Correction of traumatic tricuspid insufficiency using the double orifice technique. Asian Cardiovasc Thorac Ann. 2005;13(3):238-40.
  3. Tang GH, David TE, Singh SK, Maganti MD, Armstrong S, Borger MA. Tricuspid valve repair with an annuloplasty ring results in improved long-term outcomes. Circulation. 2006;114(Suppl): I-577–I-581.
  4. Tornos Mas P, Rodríguez-Palomares JF, Antunes MJ. Secondary tricuspid valve regurgitation: a forgotten entity. Heart. 2015; 101(22): 1
  5. Sugimoto T, Okada M, Ozaki N, et al. Long-term evaluation of treatment for functional tricuspid regurgitation with regurgitant volume: characteristic differences based on primary cardiac lesion. J Thorac Cardiovasc Surg. 1999;117(3):463-471.
  6. Lancellotti P, Tribouilloy C, Hagendorff A, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging.2013;14:611–644.
  7. Topilsky Y, Tribouilloy C, Michelena HI, et al. Pathophysiology of tricuspid regurgitation: quantitative Doppler echocardiographic assessment of respiratory dependence. Circulation 2010;122:1505–1513.
  8. Myerson SG. Heart valve disease: investigation by cardiovascular magnetic resonance. J Cardiovasc Magn Reson.2012;14:7

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Last updated: 2018-06-21 19:35