Tricuspid Regurgitation

Relevant physical signs

• Stigmata of infective endocarditis
• Signs of intravenous drug use
• Peripheral cyanosis
• Pulse rate and rhythm
• Central cyanosis
• Markedly distended jugular venous pulsation with giant v waves
  • JVP becomes more prominent with inspiration
• Chest
  • Palpation
    • Displaced apex beat (primary left-sided pathology)
    • Right ventricular heave
    • Thrill of tricuspid regurgitation
    • Palpable P2
  • Auscultation
    • Pan-systolic murmur heard loudest over the lower left sternal edge
      • Louder with inspiration (Carvallo’s sign)
    • Murmur does not usually radiate
    • S2 may be split in severe pulmonary hypertension
    • Right ventricular S3 may be present
    • Listen carefully for mid-diastolic murmur of mitral stenosis (primary lesion)
• Peripheral oedema suggesting right heart failure
• Offer to examine for:
  • Pulsatile hepatomegaly
  • Ascites
  • Stigmata of chronic liver disease

Differential diagnosis

• Tricuspid regurgitation
• Ventricular septal defect
• Mitral regurgitation

Causes of tricuspid regurgitation

• Functional
  • Pulmonary hypertension
    • Left-sided valve disease
    • Chronic lung disease
    • Chronic thromboembolic pulmonary hypertension
  • Congestive cardiac failure
• Rheumatic heart disease
• Right-sided infective endocarditis
• Carcinoid syndrome
• Ebstein’s anomaly
• Tricuspid valve prolapse

Investigation

• Electrocardiogram: rate and rhythm
• Chest radiograph: cardiomegaly, congestive cardiac failure
• Transthoracic echocardiogram: confirm diagnosis and assess severity
• Cardiac catheterization for investigation of pulmonary hypertension

Management

• Multidisciplinary team approach
• Patient education
• Cardiac rehabilitation
• Acute episodes of heart failure
  • Diuretics
  • Fluid restriction
• Cardiac cirrhosis
  • Consider referral to Hepatology
  • Oesophagogastroduodenoscopy for variceal surveillance
  • Hepatobiliary system ultrasound and alphafetoprotein for hepatocellular carcinoma surveillance
  • Check synthetic function of the liver: prothrombin time and albumin
• Functional tricuspid regurgitation
  • Percutaneous balloon valvotomy or valve replacement for mitral stenosis
  • Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension
• Indications for surgery
  • Patients with severe TR undergoing left-sided valve surgery
  • Patients with TR undergoing left-sided valve surgery AND
    • There is tricuspid annular dilation, or
    • There is right heart failure
  • Patients with severe TR unresponsive to medical therapy
  • Tricuspid valve repair generally preferred to tricuspid valve replacement (technical ease and speed)

Summary

Sir, this patient has primary tricuspid regurgitation. There is a grade 3/6 pan-systolic murmur heard loudest over the lower left sternal edge, and in inspiration. There is no right ventricular heave or loud P2 to suggest pulmonary hypertension. The apex beat is not displaced, and I was unable to auscultate any left-sided murmurs which may suggest a primary left-sided pathology. The jugular venous pressure is elevated with giant v waves, and there is peripheral oedema. In addition, there is hepatomegaly, with the liver edge felt three finger breadths under the costal margin. The liver edge is pulsatile, and there are stigmata of chronic liver disease. There are no peripheral stigmata of infective endocarditis

In summary, this patient appears to have tricuspid regurgitation, complicated by right heart failure and cardiac cirrhosis. The most common cause of tricuspid regurgitation is functional regurgitation secondary to pulmonary hypertension. However, given that there is no evidence of this on clinical examination, other possible aetiologies include infective endocarditis, rheumatic heart disease, carcinoid syndrome, tricuspid valve prolapse and Ebstein’s anomaly.