Tricuspid Regurgitation Workup

Updated: Jun 02, 2014
  • Author: Mary C Mancini, MD, PhD, MMM; Chief Editor: Richard A Lange, MD, MBA  more...
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Workup

Approach Considerations

Color flow Doppler echocardiography is a mainstay for evaluating tricuspid regurgitation. The following studies are also used in the workup:

  • Chest radiography
  • Serum chemistry
  • Electrocardiography (ECG)
  • Cardiac catheterization Serum chemistry findings in patients with tricuspid regurgitation may include abnormal liver function and hyperbilirubinemia secondary to liver congestion.

ECG findings are usually nonspecific. Typical abnormalities are incomplete right bundle-branch block, Q waves in lead V1, and atrial fibrillation.

On cardiac catheterization, right atrial pressure and right ventricular end-diastolic pressure are elevated. A rise or no change in right atrial pressure on deep inspiration is characteristic of tricuspid regurgitation. The use of angiography in this setting is controversial.

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Chest Radiography

Findings on chest radiography in patients with tricuspid regurgitation include the following:

  • Marked cardiomegaly
  • Evidence of elevated right atrial pressure may include distention of the azygous vein and pleural effusions
  • Ascites with diaphragmatic elevation may be present
  • Pulmonary arterial and venous hypertension is common
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Echocardiography

Color flow Doppler echocardiography is a mainstay for evaluating tricuspid regurgitation. Doppler techniques are used to directly visualize regurgitant jets, measure the flow velocities of the regurgitant jets, and accurately estimate right ventricular systolic pressure. See Tricuspid Valve Disease Imaging.

In trivial-to-mild tricuspid regurgitation, the jet is central and narrow. In moderate-to-severe pulmonic regurgitation, the width of the jet increases, as does the penetration of the jet into the right atrium.

European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) echocardiographic criteria for severe tricuspid regurgitation include the following [8] :

  • Abnormal/flail/large coaptation defect
  • Very large color flow central jet or eccentric wall impinging jet
  • Dense/triangular continuous-wave signal of regurgitant jet with early peaking Echocardiography is also extremely useful in determining whether the incompetence of the valve is from primary structural abnormalities of the leaflets and chordae or from secondary myocardial dysfunction and dilatation.

Other possible findings on echocardiography include the following:

  • Prolapse of the tricuspid valve, endocarditis, rheumatic heart disease, or Ebstein anomaly may be evident
  • The right ventricle is dilated
  • Paradoxical motion of the ventricular septum is observed and is similar to that found in an atrial septal defect

Using pulsed wave and continuous wave Doppler, right ventricular and pulmonary arterial systolic pressure can be estimated (using continuous wave Doppler) by measuring the peak regurgitant flow velocity across the tricuspid valve, converting it to a pressure gradient (by use of the modified Bernoulli equation), and then adding the gradient to an estimate of the right atrial pressure. [9, 10, 11]

Yang and colleagues proposed that quantification of tricuspid regurgitation by Doppler echocardiography is crucial for estimating prognosis. Their study in patients with severe isolated tricuspid regurgitation found that vena contracta width (VCW) of more than 7 mm is a powerful independent predictor of worsening heart failure, tricuspid valve surgery, and cardiovascular death. [12]

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