Tricuspid regurgitation

Source: Wikipedia, the free encyclopedia.
Tricuspid regurgitation
Other namesTricuspid insufficiency
Echocardiogram showing typical findings in severe tricuspid regurgitation
SpecialtyCardiology
SymptomsAscites[1]
CausesAbnormally high blood pressure , other heart problem[2]
Diagnostic methodEchocardiogram[2]
TreatmentDiuretic, Surgery[2]

Tricuspid regurgitation (TR), also called tricuspid insufficiency, is a type of

right ventricle, does not close completely when the right ventricle contracts (systole). TR allows the blood to flow backwards from the right ventricle to the right atrium, which increases the volume and pressure of the blood both in the right atrium and the right ventricle,[2]
which may increase central venous volume and pressure if the backward flow is sufficiently severe.

The causes of TR are divided into hereditary and acquired; and also primary and secondary. Primary TR refers to a defect solely in the tricuspid valve, such as

left ventricular failure or pulmonary hypertension.[3]

The mechanism of TR is either a dilatation of the base (annulus) of the valve due to right ventricular dilatation, which results in the three leaflets being too far apart to reach one another; or an abnormality of one or more of the three leaflets.[1]

Signs and symptoms

The symptoms of TR depend on its severity. Severe TR causes right-sided heart failure, with the development of ascites and peripheral edema.[1] In severe cases of right heart failure due to TR, venous congestion of the kidneys and liver may lead to cardiorenal syndrome (kidney failure secondary to heart failure) and cardiohepatic syndromes (liver failure secondary to heart failure) respectively.[3] Venous congestion from TR and right heart failure may also lead to anasarca (diffuse swelling) and decreased intestinal absorption due to the swelling surrounding the intestines, in severe cases this may lead to cachexia and malnutrition.[3]

A pansystolic

lower left sternal border. It increases with inspiration, and decreases with expiration: this is known as Carvallo's sign. However, the murmur may be inaudible due to the relatively low pressures in the right side of the heart. A third heart sound may also be present, also heard at the lower sternal border, and increasing in intensity with inspiration.[4][5]

On examination of the neck, there may be giant C-V waves in the jugular pulse.[6] With severe TR, there may be an enlarged liver detected on palpation of the right upper quadrant of the abdomen; the liver may be pulsatile on palpation and even on inspection.[7]

Causes

The causes of TR may be classified as congenital

cor pulmonale.[3]

In regards to primary and secondary causes they are:[9]

Pathological specimen and ultrasound image of a heart with Ebstein's anomaly
  • Primary causes
    • Rheumatic
    • Myxomatous
    • Ebstein anomaly
    • Endomyocardial fibrosis
    • Endocarditis
    • Traumatic (blunt chest injury)
  • Secondary causes

Mechanism

In terms of the mechanism of tricuspid insufficiency, it involves the expansion of the tricuspid

myocardium around the annulus.[11]

Diagnosis

The diagnosis of TR may be suspected if the typical murmur of TR is heard or other signs suggestive of right heart failure.[citation needed]

Definitive diagnosis is made by

Cardiac MRI or CT scan may also aid in the diagnosis of TR.[3] On imaging studies, a regurgitant volume greater than 45 milliliters or greater than 50% regurgitation across the tricuspid valve is associated with poor outcomes.[3]

Management

Medical

Medical therapy for tricuspid regurgitation consists of diuretics (

renin–angiotensin–aldosterone system, which leads to the kidneys reabsorbing salt and water and vasoconstriction of the arterioles.[3] Intestinal edema may also lead to decreased gut absorption of the diuretics and increased fluid retention may lead to an increased volume of distribution of the diuretic.[3] All of the preceding mechanisms in TR with right heart failure (and sometimes secondary left heart failure) lead to diuretic resistance. Diuretic resistance is associated with a poor prognosis.[3]

Surgical

Indications for surgical fixation of tricuspidal issues include organic lesion(s) in the valve or severe functional regurgitation. During open heart surgery for another issue (e.g. mitral valve), fixing the tricuspid valve may be considered, but medical consensus is unclear. Some argue that even mild to moderate tricuspid regurgitation should be addressed, while others take a more conservative approach. Infective endocarditis or traumatic lesions are other indications.[14]

Surgical options include annuloplasty or replacement of the valve. Adding a rigid prosthetic ring aims to decrease the diameter of the valve and stabilize it. Another annuloplasty modality is the "De Vega technique", in which the valve diameter is decreased by two sutures placed around the periphery of the valve. In cases of severe organic lesions of the valve, such as endocarditis, the valve may be excised. Tricuspid valve replacement with either a mechanical valve or a bioprosthesis may be indicated depending on the patient.[15] Mechanical prostheses can cause thromboembolic phenomena, while bioprostheses may degenerate with use.[11] Some evidence suggests that there is no significant difference between the survival rates of recipients of mechanical versus biological tricuspid valves.[16][15]

When controlled for severity of TR, tricuspid valve surgery performed on TR patients as considered appropriate is associated with improved outcomes (Hazard ratio= .74).[17]

Prognosis

The prognosis of TR is less favorable for females than males. Females are at a greater risk of progressing to severe TR as compared to males.[3] Survival rates are proportional to TR severity;[18] but even mild TR reduces survival compared to those with no TR. In some studies, the 1 year mortality rate of severe, medically treated TR is 36-42% with a 2-3.2 times increased risk of death in moderate or severe TR as compared to mild TR or no tricuspid valvular disease.[3] Even in those with mild TR, a large population based study showed about a 29% greater risk of death as compared to healthy controls.[19]

Epidemiology

In The

right ventricular volume overload.[22]

In a study of 595 male elite football players aged 18–38, and 47 sedentary non-athletes, it was found that 58% of the athletes had tricuspid regurgitation vs. 36% in non-athletes. Football players with tricuspid regurgitation had larger tricuspid annulus diameter, compared to athletes without tricuspid regurgitation. Athletes with tricuspid regurgitation also had enlarged right atrium diameter when compared to control group.[23]

See also

  • Heart valves

References

  1. ^ a b c Tricuspid Regurgitation~clinical at eMedicine
  2. ^ a b c d MedlinePlus Encyclopedia: Tricuspid regurgitation
  3. ^
    doi:10.1056/NEJMra2216709
    .
  4. ^ "Tricuspid Valve Disease & Tricuspid regurgitation (TR) | Patient". Patient. Retrieved 2015-12-14.
  5. ISBN 9780781741903
    .
  6. PMID 24224640
    .
  7. doi:10.1016/0002-9149(93)90810-Y
    .
  8. PMID 24084288
    .
  9. PMID 19470900
    .
  10. PMID 20813321
    .
  11. ^
    PMID 17228081
    .
  12. ^ Shah PM, Raney AA; Tricuspid valve disease. Curr Probl Cardiol. 2008 Feb33(2):47-84
  13. PMID 29892601
    .
  14. ^ Mestres, Bernal & Pomar 2016, chapter 81 Surgical Treatment of Tricuspid Valve Diseases#Indications for Surgery.
  15. ^ a b Mestres, Bernal & Pomar 2016, chapter 81 Surgical Treatment of Tricuspid Valve Diseases#Tricuspid Valve Surgery.
  16. ^ "BestBets: Should the tricuspid valve be replaced with a mechanical or biological valve?". www.bestbets.org. Retrieved 2015-12-14.
  17. PMID 29246545. – via ScienceDirect
     (Subscription may be required or content may be available in libraries.)
  18. PMID 15013122
    .
  19. doi:10.1016/j.echo.2022.04.003
    .
  20. PMID 10190406
    .
  21. doi:10.1093/eurheartj/ehv487
    .
  22. PMID 26358570
    .
  23. PMID 26509381
    .

Sources

Further reading

External links

Scholia has a topic profile for Tricuspid regurgitation.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Tricuspid_regurgitation&oldid=1182176619"