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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:

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]
  • 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]
  • 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]
Falling
  • Heart valve problems fall into two major categories: Stenosis – The opening of the valve is too narrow, and this interferes with the forward flow of blood Regurgitation – The valve doesn't close properly.[health.harvard.edu]
  • As pulmonary vascular pressures fall with successful mitral valve therapy, the tricuspid regurgitation tends to disappear. Surgical options include annuloplasty and valve replacement.[emedicine.medscape.com]
  • If the volume of blood ejected into the aorta is sufficiently reduced, then aortic pressure may fall (110/75 mmHg in this example).[cvphysiology.com]
Anemia
  • Structural heart defects and extracardiac diseases (e.g. high output cardiac failure in arteriovenous shunts and anemia) were excluded by Doppler echocardiography and fetal blood sampling.[ncbi.nlm.nih.gov]
  • These factors include noncompliance with medication or diet; use of medications such as nonsteroidal antiinflammatory drugs, nondihydropyridine calcium channel blockers, and antiarrhythmic drugs; systemic factors such as sepsis, anemia, high-output state[doi.org]
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]
  • 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]
  • 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]
  • 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
  • CONCLUSIONS: In patients with severe tricuspid regurgitation undergoing left ventricular assist device implantation, a concomitant tricuspid valve procedure effectively reduces tricuspid regurgitation and promotes reverse remodeling of the right ventricle[ncbi.nlm.nih.gov]
  • 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.[symptoma.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]
  • Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier Saunders; 2019:chap 70. Rosengart TK, Anand J. Acquired heart disease: valvular. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds.[nlm.nih.gov]
  • 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]
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.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]
  • 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]
  • 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]
Pansystolic Murmur
  • Common findings include distended jugular veins, hepatomegaly, pansystolic murmur auscultated in the parasternal area at the 4th intercostal space.[symptoma.com]
  • Cardiac murmurs are often present: A pansystolic murmur, which may signify blood flow through the ventricular septal defect.[patient.info]
  • 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]
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]
  • 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]
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]
Cesarean Section
  • At 35 weeks' gestation, Cesarean section was performed, because of increased tricuspid valve insufficiency, and a healthy boy was born. After birth, right heart dilatation and tricuspid valve insufficiency decreased.[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 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]

Treatment

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

Etiology

  • 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.com]

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]
  • In this article, we review the anatomy, pathophysiology, and value of mechanical correction of TR, including potential transcatheter therapies for TR.[ncbi.nlm.nih.gov]
  • 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]

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. inquire@heart.org. .[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 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]

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: 2019-06-28 09:46