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:

• 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) [5]

• Fatigue

  Tricuspid regurgitation may not have any symptoms or the symptoms be vague, such as weakness and fatigue, which develop because the heart is not pumping enough blood to allow the body to receive the needed oxygen. [heart.org]

  Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate)Marked limitation. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. [clinicaltrials.gov]

  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]

  Low output symptoms of fatigue, anorexia, wasting, peripheral cyanosis and cold skin. Usually those of accompanying left-sided rheumatic valve lesions. [patient.info]

  Most patients are asymptomatic, but those who do experience symptoms complain of fatigue and/or liver pain. [ihimontanafoundation.org]

• Swelling

  Symptoms of heart failure may occur, and can include: Active pulsing in the neck veins Decreased urine output Fatigue, tiredness General swelling Swelling of the abdomen Swelling of the feet and ankles Weakness Exams and Tests The health care provider [nicklauschildrens.org]

  Other symptoms may include: Active pulsing in the neck veins Enlarged liver Fatigue or weakness Abdominal swelling Swelling in the legs, ankles, and/or feet Treatment options may include: Treatment may not be required if the symptoms are not bothersome [heart.org]

  These include: High blood pressure in the lungs Swelling of the right lower heart chamber Surgical valve repair or replacement most often provides a cure in people who need an intervention. [nlm.nih.gov]

  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]

• Weakness

  The physical examination may also reveal jaundice, peripheral edema, ascites, weak peripheral pulse, pulmonary rales, and an S3 or S4 gallop. [symptoma.com]

  Tricuspid regurgitation may not have any symptoms or the symptoms be vague, such as weakness and fatigue, which develop because the heart is not pumping enough blood to allow the body to receive the needed oxygen. [heart.org]

  Symptoms are vague, such as weakness and fatigue. Doctors make the diagnosis because of physical examination findings, and they use echocardiography to confirm the diagnosis. The underlying disorder needs to be treated. [merckmanuals.com]

  Blood: Any fever that last longer than two days and is accompanied by chills, weakness, general feeling of ill health. [hopkinsmedicine.org]

• Ankle Swelling

  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]

• Dyspnea

  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]

  Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. Class III (Moderate)Marked limitation. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. [clinicaltrials.gov]

  Common presenting complaints in patients with RV dysfunction include the following: Dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea Ascites Peripheral edema Exercise intolerance may also be observed. [emedicine.medscape.com]

  Three weeks later, he presented with right-side heart failure symptoms and dyspnea on minimal exertion. A transesophageal echocardiogram (TEE) ( Figure 4 ) demonstrated severe TR and enlargement of the right ventricle. [innovationsincrm.com]

  Dilated Cardiomyopathy and Pulmonary Congestion Pulmonary Congestion or Edema of Cardiac and Other Origins Causes and Pathogenesis of Pulmonary Edema Cardiac Origins of Peripheral or Systemic Congestion or Edema Therapy for Pulmonary Edema and Paroxysmal Dyspnea [euro-libris.ro]

• Regurgitation

  Rheumatic disease is the most common cause of pure tricuspid regurgitation due to deformation of the leaflets. Endocarditis is an important cause of tricuspid regurgitation. [emedicine.medscape.com]

  In patients with severe (3+/4+) preoperative tricuspid regurgitation, mitral valve repair alone reduced tricuspid regurgitation and improved right ventricular function; however, tricuspid regurgitation of 2+ or greater returned and right ventricular function [ncbi.nlm.nih.gov]

• Heart Disease

  Always tell your health care provider and dentist if you have a history of heart valve disease or congenital heart disease before treatment. Some people may need to take antibiotics before having a procedure. [nlm.nih.gov]

  Surgical treatment of tricuspid regurgitation in congenital heart disease should be performed before the onset of heart failure. [ncbi.nlm.nih.gov]

  […] in adults with congenital heart disease. [books.google.com]

  Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). [emedicine.medscape.com]

• 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]

  Heart murmurs are frequently absent and blood cultures may be negative. Annular abscesses are not uncommon. [emedicine.medscape.com]

  Heart sounds and murmurs: High-pitched pansystolic murmur, most prominent in the fourth intercostal space in the left parasternal region. In the absence of pulmonary hypertension, the murmur is usually low-intensity and early systolic. [patient.info]

• Mitral Valve Prolapse

  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]

  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]

  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]

  Ebstein's anomaly of the tricuspid valve with associated mitral valve prolapse. Tex Heart Inst J. 2001. 28(1):72. [Medline]. Simula DV, Edwards WD, Tazelaar HD, et al. [emedicine.medscape.com]

  Based on these data, the indications for tricuspid repair, at the time of mitral repair for mitral valve prolapsed, continue to be debatable. [icrjournal.com]

• Jugular Venous Distention

  Jugular venous distention may occur; severe TR may cause abdominal distension, hepatic enlargement, and peripheral edema. [merckmanuals.com]

  Physical Examination Findings on cardiovascular examination in patients with tricuspid regurgitation include the following: S 3 gallop Jugular venous distention with a prominent V wave In some patients, a pansystolic murmur Diminished peripheral pulse [emedicine.medscape.com]

  The physical examination was significant for jugular venous distention, Grade II/VI holosystolic murmur at the left sternal border, and lower extremity +2 edema. An echocardiogram ( Figure 2 ) showed severe TR with signs of volume overload. [innovationsincrm.com]

• Cyanosis

  Low output symptoms of fatigue, anorexia, wasting, peripheral cyanosis and cold skin. Usually those of accompanying left-sided rheumatic valve lesions. [patient.info]

  During the examination the doctor determines the presence of cyanosis of the skin, swelling of the veins in the neck and abdomen (ascites occurs when due to the accumulation of excess fluid). [vascular.vsebolezni.com]

  Frequently, congestive heart failure, persistent cyanosis, and ECG evidence of myocardial ischemia were present. Twelve of the 14 survived, and in each of them all cardiac signs and symptoms, including the murmur, spontaneously resolved. [pediatrics.aappublications.org]

  In late stages and with hepatic insufficiency, cachexia (loss of weight and fatigue), jaundice and cyanosis may develop. Upon suspicion of tricuspid regurgitation: TTE: 2D transthoracic echocardiography (TTE) is the technique of choice. [escardio.org]

• Hepatomegaly

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

  Blood flow into the pulmonary circulation is impaired and is accompanied by peripheral oedema and hepatomegaly. [patient.info]

  His recent chest radiograph revealed increased cardiothoracic ratio and ultrasound abdomen showed hepatomegaly. [omicsonline.org]

  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]

• Jaundice

  The physical examination may also reveal jaundice, peripheral edema, ascites, weak peripheral pulse, pulmonary rales, and an S3 or S4 gallop. [symptoma.com]

  […] to decrease volume overload Pulmonary rales, if the tricuspid regurgitation is associated with left ventricular dysfunction or mitral stenosis Right ventricularheave and S 4 gallop that increases with inspiration Ascites Peripheral edema Cachexia and jaundice [emedicine.medscape.com]

  In late stages and with hepatic insufficiency, cachexia (loss of weight and fatigue), jaundice and cyanosis may develop. Upon suspicion of tricuspid regurgitation: TTE: 2D transthoracic echocardiography (TTE) is the technique of choice. [escardio.org]

• Pulsatile Liver

  Fatigue, weakness, shortness of breath, jugular vein distension, ascites, hepato-splenomegaly, pulsatile liver, pleural effusions and peripheral oedema may be present. [escardio.org]

• Asthenia

  When symptoms appear, patients may complain of asthenia, fatigue or decreased exercise tolerance as a result of lower cardiac output. [heart.bmj.com]

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 V-Waves

  Physical Examination Findings on cardiovascular examination in patients with tricuspid regurgitation include the following: S 3 gallop Jugular venous distention with a prominent V wave In some patients, a pansystolic murmur Diminished peripheral pulse [emedicine.medscape.com]

  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 A-Wave

  Physical Examination Findings on cardiovascular examination in patients with tricuspid regurgitation include the following: S 3 gallop Jugular venous distention with a prominent V wave In some patients, a pansystolic murmur Diminished peripheral pulse [emedicine.medscape.com]

  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]

He was discharged home with slight tricuspid regurgitation, without signs of hemodynamic decompensation, and required no further treatment. [ncbi.nlm.nih.gov]

Treatment Approach Considerations The choice of treatment for tricuspid regurgitation depends on the etiology and severity of the condition. Medical therapy may be used in tricuspid regurgitation secondary to left-sided heart failure. [emedicine.medscape.com]

Treatment may not be needed if there are few or no symptoms. You may need to go to the hospital to diagnose and treat severe symptoms. [nlm.nih.gov]

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]

Tricuspid regurgitation is a frequent echocardiographic finding; however, the association with prognosis is unclear. [ncbi.nlm.nih.gov]

Outcome after discharge: follow-up and long-term prognosis 11.1 Recurrences: relapses and reinfections 11.2 Short-term follow-up 11.3 Long-term prognosis 12. [escardio.org]

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]

Functional tricuspid regurgitation (TR) is a common etiology of TR. [ncbi.nlm.nih.gov]

In persons with an anatomically normal tricuspid valve, a common etiology of tricuspid regurgitation is dilatation of the RV cavity. [emedicine.medscape.com]

In the present paper, we review the anatomy of the normal TV, the pathophysiology of FTR, the assessment of its severity and functional significance, and propose an algorithm for selecting patients for surgical treatment. [ncbi.nlm.nih.gov]

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]

Management of specific situations 12.1 Prosthetic valve endocarditis 12.1.1 Definition and pathophysiology 12.1.2 Diagnosis 12.1.3 Prognosis and treatment 12.2 Infective endocarditis affecting cardiac implantable electronic devices 12.2.1 Introduction [escardio.org]

"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. PMID 18378625. [en.wikipedia.org]

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. [medical-dictionary.thefreedictionary.com]

[…] of systemic embolism 8.3.1 Embolic events in infective endocarditis 8.3.2 Predicting the risk of embolism 8.3.3 Indications and timing of surgery to prevent embolism in infective endocarditis 9. [escardio.org]

Prevent infective endocarditis. If you have had a heart valve replaced, your doctor may recommend you take antibiotics before dental procedures to prevent an infection called infective endocarditis. [mayoclinic.org]

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]

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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