Tricuspid regurgitation

Question 1

Define tricuspid regurgitation

Answer 1

Backflow of blood from the right ventricle to the right atrium during systole

Question 2

Explain the aetiology/risk factors for tricuspid regurgitation

Answer 2

Congenital - Ebstein’s anomaly (malpositioned tricuspid valve), Cleft valve in ostium primum

Functional - Consequence of right ventricular dilation (e.g. due to pulmonary hypertension), Valve prolapse

Rheumatic Heart Disease

Infective Endocarditis

Other: carcinoid syndrome, trauma, cirrhosis, iatrogenic

Question 3

Summarise the epidemiology of tricuspid regurgitation

Answer 3

Differs based on cause

Infective endocarditis is the MOST COMMON cause

Question 4

Recognise the presenting symptoms of tricuspid regurgitation

Answer 4

Fatigue
Breathlessness
Palpitations
Headaches
Nausea
Anorexia
Epigastric pain made worse by exercise
Jaundice
Lower limb swelling

Question 5

Recognise the signs of tricuspid regurgitation on physical examination

Answer 5

Pulse-irregularly irregular if AF

Raised JVP with giant V waves (which may oscillate the earlobes) This is caused by transmission of
high right ventricular pressures into the great veins
(Giant A waves may also be present)

Palpation-parasternal heave

Pansystolic murmur - heard best at lower left sternal edge, Louder on inspiration (Carvallo sign)

Loud P2 component of second heart sound

Pleural effusion
Causes of pulmonary hypertension
Palpable liver (tender, smooth and pulsatile)
Ascites
Pitting oedema

Question 6

Identify appropriate investigation for tricuspid regurgitation

Answer 6

FBC
LFT
Cardiac enzymes
Blood cultures

ECG - P pulmonale - due to right atrial hypertrophy

CXR - Right-sided enlargement of cardiac shadow

Echocardiography - Extent of regurgitation can be estimated using

Doppler ultrasound - May show valve prolapse and right ventricular dilation

Right Heart Catheterisation - Rarely necessary but may be useful for assessing pulmonary artery pressure