Tricuspid Regurgitation

Question 1

Tricuspid regurgitation is often ______________ and ____________ to RV pressure or volume overload

It may be a primary abnormality related to endocarditis, rheumatic disease, trauma, or tricuspid injury from pacemaker leads.

Functional TR is typically seen in association with PH that is at least ______________ in severity; however, TR and RV failure may be secondary to ____________ or a __________________ with no or mild PH.

Answer 1

Functional and secondary
Moderate PH
ASD
Primary RV disorder

Question 2

Hemodynamics of Severe functional TR or decompensated or acute organic TR
-RA pressure
-RA waves and RA tracing
-RV tracing

Answer 2

Increased RA pressure
Increased RA V wave (V wave larger than 1.5 times mean RA pressure or a V wave larger than mean RA pressure by greater than 5 mm Hg)
Flat X wave (systolic flow blunting)
Deep Y descent
The V wave may be so large and wide that it simulates RV tracing (“ventricularized” RA pressure tracing); very specific for TR

RA fills from venous return but also from the regurgitant volume during systole, which leads to a high V wave, preceded by a flattened X descent, and followed by a deep Y descent

V wave size correlates inversely with atrial compliance
Deep X and deep Y descents reflect loss of atrial and ventricular compliances, wherein atrial pressure goes sharply down and then up

Question 3

Effects of inspiration in severe TR

Answer 3

The regurgitant volume increases with inspiration, and therefore, RA pressure increases and V wave and Y descent become more ample during inspiration

This is a characteristic feature of TR and of RV failure that distinguishes them from normal subjects (where RA pressure decreases with inspiration because of the direct effect of the negative intrathoracic pressure)

Deep inspiration may induce a ventricularization pattern in patients with normal RA pressure contour

Question 4

Hemodynamics of MR, AR and TR

Question 5

PA/RV Systolic pressure in Primary vs Secondary TR

Answer 5

Primary - < 40 mm Hg
Secondary - > 55 mm Hg

Question 6

Conditions that may simulate severe TR

Answer 6

Constrictive Pericarditis - DEEP X and DEEP Y; dip and plateau pattern on RV tracing, equalization of end-diastolic pressures of the 4 cardiac chambers, and sometimes respiratory discordance of RV/LV systolic peaks

RV Failure - prominent V wave is also seen in cases of decompensated RV failure with RA volume overload that surpasses RA compliance; Mean RA pressure, V wave, and mean RV diastolic pressure are increased in RV failure (an elevated RA pressure defines RV failure)

Review:
-Deep X and deep Y: constrictive pericarditis
-Deep X and flat Y (diastolic flow blunting): tamponade, but also sinus tachycardia (mnemonic: Flat Y Tamponade=FYT)
-Flat X (systolic flow blunting) and deep Y: severe TR and/or RV failure
-Large V wave: severe TR and/or RV failure
-Ventricularized RA pressure: severe TR