7th March 2024

Tricuspid Regurgitation

Moderate or severe tricuspid regurgitation (TR) is observed in 0.55% of the general population and its prevalence increases with age, affecting about 4% of the patients aged 75 years or more. 

Aetiology

Aetiology is secondary in over 90% of cases, due to pressure and/or volume overload mediated RV dilatation or enlarged right atrium and tricuspid annulus due to chronic AF. 

Cardiac implantable electronic device-lead implantation leads to progressive tricuspid regurgitation in 20-30% of patients. 

Other causes include pulmonary hypertension (e.g. Secondary to COPD), rheumatic heart disease, infective endocarditis, Ebstein’s anomaly and carcinoid syndrome.  

Mild or moderate tricuspid regurgitation without abnormal valve anatomy, ventricular function, or pulmonary artery pressure is not necessarily abnormal but is estimated to be present in over 50% of asymptomatic young adults.

Clinical manifestations

Tricuspid regurgitation usually presents with fatigue, dyspnoea, and lower extremity oedema. Additional complaints may include abdominal distension and early satiety. 

Clinical examination reveals an abnormal and prominent v wave and a left lower parasternal systolic murmur (holosystolic or less than holosystolic, depending on the severity of haemodynamic derangement) which is increased on inspiration (Carvallo’s sign). 

Diagnosis

ECG may show AF, evidence of RV strain or evidence of previous myocardial infarction. An echocardiogram is needed to confirm the diagnosis. In secondary TR, annular dilatation is seen with a raised pulmonary artery pressure. 

Management 

Treatment is focused on managing the underlying cause and regular follow up. Medical management of heart failure and risk factor modification is also advised. Severe disease can be treated with annuloplasty or tricuspid valve replacement. Surgery should be considered for medically refractory right heart failure, imminent or existing atrial fibrillation, or progressive right ventricular dilation and dysfunction.