Tricuspid Regurgitation

• Incompetent tricuspid valve -> allows blood to flow back from RV to RA during systole -> decreased CO & elevated RA pressure (severe disease) -> atrial distension with reduced contractile reserve & AF (if long-standing)
• What is the severity of TR based on?


  Echo measurement of annular diameter

  • Normal = 28 mm (± 5 mm)
  • Significant tricuspid annular dilation = diastolic diameter of over 40 mm (absolute value) or 21 mm/square metre of body surface area
  • Markers of more significant TR = systolic tricuspid diameter >3.2 cm OR diastolic tricuspid annulus diameter >3.4 cm
• What are the signs & symptoms of TR?

  Fatigue

  SOB

  Palpitations

  Irregular heart rhythm

  Pan systolic murmur (heard loudest over tricuspid region)

  Split S2 (due to pulmonary valve closing earlier than aortic valve)

  Thrill in tricuspid area on palpitation

  Raised JVP (with giant C-V waves)

  Pulsatile liver (due to regurgitation into venous system)

  Peripheral oedema
• What are the possible causes of TR?


  LHF

  IE

  Rheumatic heart disease

  Carcinoid syndrome

  Ebstein's anomaly

  Connective tissue disorders (e.g. Marfan syndrome)
• What are the investigations for TR?


  Obs

  Full Hx & examination

  ECG

  Bloods (FBC, LFTs, U&Es, CRP)

  Echo

  • to assess L & R heart EF
  • may show regional wall motion abnormalities

  CXR

  • assess for HF or enlargement
  • may show cardiomegaly, pleural or pericardial effusion
• What are the different types of TR?


  Primary -> abnormal valve morphology

  Secondary -> normal valve morphology
• What is the treatment for primary TR?


  Depends on severity:

  Mild/moderate

  • Treat underlying cause + follow up
  • Consider HF management & RF modification

  Severe

  • Asymptomatic
  • Treat underlying cause + follow up
  • Consider HF management & RF modification
  • Consider surgery
  • Symptomatic
  • Treat underlying cause + follow up + tricuspid valve replacement or annuloplasty (1st line)
  • Consider HF management & RF modification
• What is the treatment of secondary TR?


  Depends on severity:

  Mild/moderate

  • Treat underlying cause + follow up (1st line)
  • Consider tricuspid valve replacement or annuloplasty
  • Consider HF management & RF modification

  Severe

  • Treat underlying cause + follow up
  • PLUS tricuspid valve repair (if required)
  • Consider HF management & RF modification
• What is tricuspid regurgitation?

  Backflow of blood through the tricuspid valve