Tricuspid insufficiency

Tricuspid insufficiency
ICD-10	I07.1, I36.1
ICD-9	397.0
DiseasesDB	13348
MeSH	D014262

Template:Search infobox Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Tricuspid insufficiency, a valvular heart disease also called Tricuspid regurgitation, refers to the failure of the heart's tricuspid valve to close properly during systole. As a result, with each heart beat, blood is pumped out from the right side of the heart in the opposite direction to normal.

Causes

Although congenital causes of tricuspid insufficiency exist, most cases are due to dilation of the right ventricle. Such dilation leads to derangement of the normal anatomy and mechanics of the tricuspid valve and the muscles governing its proper function. The result is incompetence of the tricuspid valve. Common causes of right ventricular dilation include left heart failure, pulmonary hypertension, and right ventricular infarction.

One notable exception to right ventricular dilation as a cause of tricuspid insufficiency occurs in right-sided endocarditis (i.e. infection affecting the right side of the heart). In that case, there is direct damage to the tricuspid valve as a result of infection.

Symptoms and Signs

Tricuspid insufficiency may be asymptomatic, especially if right ventricular function is well preserved. Conversely, edema, vague upper abdominal discomfort (from a congested liver), and fatigue (due to diminished cardiac output) can all be present to some degree. On examination, the jugular venous pressure is usually elevated, and 'CV' waves can be seen. The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency). Peripheral edema is often found. In severe cases, there may be ascites and even cirrhosis (so-called 'cardiac cirrhosis).

Triscuspid insufficiency may lead to the presence of a pansystolic heart murmur. Such a murmur is usually of low frequency and best heard low on the left sternal border. It tends to increase with inspiration. However, the murmur may be inaudible reflecting the relatively low pressures in the right side of the heart. A third heart sound may also be present.

Physical Examination

Clinical findings found in patients presenting with tricuspid regurgitation are as a result of right sided heart failure and regurgitant blood flow across the tricuspid valve into the right atria during ventricular contraction. Patients with right sided heart failure may present with peripheral edema, cyanosis, hepatosplenomegaly, ascitis, cachexia and jaundice. Signs of left sided heart failure will dominate in case of left ventricular dysfunction.

Neck

• JVP is prominent and jugular venous distention is present
• "V wave" is prominent as a result of systolic regurgitation into right atrium.
• Severe regurgitation can also present as systolic thrill over jugular vein.

Heart

Palpation

• Right ventricular heave or lift may be present due to right ventricular enlargement.
• In presence of pulmonary hypertension, dilated pulmonary artery may result in pulsations felt over the left second intercostal space.

Auscultation

Heart Sounds

• "S3 Gallop" is present because of dilated right ventricle.
• Fourth heart sound (S4) may be present because of right ventricular hypertrophy.
• Pulmonic component of second heart sound (P2) is accentuated if pulmonary hypertension is present.
• Splitting of second heart sound (S2) may be notable if pulmonary hypertension is present.

Murmurs

• Holosystolic murmur is present
• Best heard at the right or left fourth intercostal space
• In presence of right ventricular enlargement, murmur is also audible at the cardiac apex.
• Inspiration, leg raising, exercise and hepatic compression make the murmur loud by increasing venous return to the heart.
• Standing, amyl nitrate and valsalva maneuver make the murmur soft by decreasing venous return to the heart.
• Diastolic rumble may be present because of increased blood flow across the tricuspid valve during diastole.

Liver

• Hepatomegaly may be present.
• Thrill may be present due to transmission of systolic murmur to liver.

Lungs

• Pulmonary rales might be present if left ventricular dysfunction is associated with the disease.

Diagnosis

Diagnosis is usually made by echocardiography although the find of a pulsatile liver and/or the presence of prominent CV waves in the jugular pulse is also essentially diagnostic.

• Flail Tricuspid with Severe Tricuspid Regurgitation and Right Ventricular Overload 1

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• Flail Tricuspid with Severe Tricuspid Regurgitation and Right Ventricular Overload 2

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• Flail Tricuspid with Severe Tricuspid Regurgitation and Right Ventricular Overload 3

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• Flail Tricuspid with Severe Tricuspid Regurgitation and Right Ventricular Overload 4

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• Flail Tricuspid with Severe Tricuspid Regurgitation and Right Ventricular Overload 5

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• Severe Tricuspid Regurgitation 1

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• Severe Tricuspid Regurgitation 2

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• Severe Tricuspid Regurgitation with dilated Right Ventricle and Severe Pulmonary Hypertension 1

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• Severe Tricuspid Regurgitation with dilated Right Ventricle and Severe Pulmonary Hypertension 2

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• Severe Tricuspid Regurgitation with dilated Right Ventricle and Severe Pulmonary Hypertension 3

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• Severe Tricuspid Regurgitation with dilated Right Ventricle and Severe Pulmonary Hypertension 4

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Cardiac MRI in Tricuspid insufficiency

ACC/AHA Guidelines- ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance (DO NOT EDIT)

“

CMR may be used for assessing individuals with valvular heart disease in which evaluation of valvular stenosis, regurgitation, para- or perivalvular masses, perivalvular complications of infectious processes, or prosthetic valve disease are needed. CMR may be useful in identifying serial changes in LV volumes or mass in patients with valvular dysfunction.

”

Therapy

In most cases, surgery is not indicated since the root problem lies with a dilated or damaged right ventricle. Medical therapy with diuretics is the mainstay of treatment. Unfortunately, this can lead to volume depletion and decreased cardiac output. Indeed, one must often accept a certain degree of symptomatic tricuspid insufficiency in order to prevent a decrease in cardiac output. Treatment with medicines to reduce cardiac afterload may also be of benefit but a similar risk of depressed cardiac output applies.