History
Patients with tricuspid regurgitation present with the signs and symptoms of right-sided heart failure. The spectrum of presenting symptoms depends on whether the condition is secondary to right ventricular (RV) dilatation or other conditions (eg, left ventricular [LV] dysfunction).
Common presenting complaints in patients with RV dysfunction include the following:
-
Dyspnea on exertion
-
Orthopnea
-
Paroxysmal nocturnal dyspnea
-
Ascites
-
Peripheral edema
Exercise intolerance may also be observed. Rarely, patients report angina, which may result from RV overload and strain, even in the absence of coronary artery disease. [7]
These patients, especially those experiencing febrile episodes, must be questioned regarding risk factors for infective endocarditis , which is a common cause of tricuspid valvular disease. Risk factors include intravenous drug use, alcoholism, and a history of rheumatic fever.
Physical Examination
Findings on cardiovascular examination in patients with tricuspid regurgitation include the following:
-
S3 gallop
-
Jugular venous distention with a prominent V wave
-
In some patients, a pansystolic murmur
-
Diminished peripheral pulse volume secondary to impaired forward blood flow; patients with this sign may have relative hypotension secondary to therapeutic interventions used to decrease volume overload
-
Pulmonary rales, if the tricuspid regurgitation is associated with left ventricular dysfunction or mitral stenosis
-
Right ventricular heave and S4 gallop that increases with inspiration
-
Ascites
-
Peripheral edema
-
Cachexia and jaundice
The pansystolic murmur associated with tricuspid regurgitation is high pitched and is loudest in the fourth intercostal space in the parasternal region. The murmur is usually augmented during inspiration and is reduced in intensity and duration in the standing position and during a Valsalva maneuver. A short, early diastolic flow rumble may be present due to increased flow across the tricuspid valve.
Tables
Recommendation |
AHA/ACC (2014) [23] |
ESC/EACTS (2012) [8] |
Tricuspid valve surgery for patients with severe tricuspid regurgitation(TR) or severe tricuspid stenosis (TS) when undergoing left-sided valve surgery |
Class I |
Class I |
Tricuspid valve surgery for patients with isolated, symptomatic severe TS. |
Class I |
Class I |
Tricuspid valve surgery for patients with isolated, symptomatic severe TR without severe right ventricle dysfunction |
Class I |
|
Tricuspid valve repair for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) tricuspid annular dilation or 2) prior evidence of right HF |
Class IIa-Reasonable |
Class IIa-Reasonable |
Tricuspid valve surgery for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D). |
Class IIa-Reasonable |
|
After left-sided valve surgery, surgery for patients with severe TR who are symptomatic or have progressive right ventricular dilatation/dysfunction, in the absence of left-sided valve dysfunction, severe right or left ventricular dysfunction, and severe pulmonary vascular disease |
Class IIa-Reasonable |
|
Tricuspid valve repair for patients with moderate functional TR (stage B) and pulmonary artery hypertension at the time of left-sided valve surgery |
Class IIb-Consider |
|
Tricuspid valve surgery for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction. |
Class IIb-Consider |
Class IIa-Reasonable |
Reoperation for isolated tricuspid valve repair or replacement for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe pulmonary hypertension or significant RV systolic dysfunction. |
Class IIb-Consider |
|
Percutaneous balloon tricuspid commissurotomy in patients with isolated, symptomatic severe TS without accompanying TR. |
Class IIb-Consider |
