Symptoms

Patients present with clinical features of right-sided heart failure. These may be painful hepatosplenomegaly, ascites, and peripheral edema. In severe cases, pulsations in the neck from the distended and pulsatile jugular veins is noted. Exercise intolerance may be seen. Clinical features of the underlying condition causing tricuspid regurgitation may be observed. For example, pulmonary hypertension may cause symptoms such as weakness, shortness of breath, and exercise intolerance or patients presenting with infective endocarditis, a common cause of tricuspid regurgitation, may present with febrile episodes.

Physical Examination

• Jugular venous distension with a prominent V wave reflects the elevation in right atrial pressure. Increase in venous return causes jugular venous distension, and it is more prominent with inspiration (Kussmaul’s sign).
• S3 gallop is associated with an extremely dilated RV.
• Pansystolic murmur: It is high pitched and loudest in the fourth intercostal space in the parasternal region. The intensity of the murmur increases during inspiration, exercise, leg raising (due to increase in venous return) and decreases in standing position and during Valsalva maneuver.
• Ascites
• Cachexia and jaundice
• Atrial fibrillation
• Peripheral edema
• Right ventricular heave due to dilated right ventricle and S4 gallop that increases with inspiration

The main modality used to diagnose and evaluate tricuspid regurgitation is Doppler echocardiography. It is used to precisely contemplate regurgitant blood flow and its flow velocity and accurately measure the systolic pressure in the right ventricle

Echocardiographic Findings

• Tricuspid valve motion may be normal or abnormal. Characteristic primary valvular abnormalities include Ebstein anomaly, leaflet prolapse, flail leaflet, endocarditis, carcinoid heart disease, and rheumatic valve disease.
• The dilated right atrium and right ventricle in the presence of moderate to severe tricuspid regurgitation
• The tricuspid annulus is often dilated.
• The paradoxical interventricular septal movement that reflects the increased volume within the right ventricle (diastolic overload)
• Right ventricle function that may be hyperdynamic, normal, or reduced, thus reflecting the underlying cause of tricuspid regurgitation and the degree of RV compensation.
• Other abnormalities may be seen when the tricuspid regurgitation are due to pulmonary hypertension secondary to a left-sided cardiac abnormality.
• The peak regurgitant flow velocity across the tricuspid valve is measured which helps in estimating the right ventricular and pulmonary arterial systolic pressure. The modified Bernoulli equation is used to convert it to a pressure gradient following which the gradient is added to an estimate of the right atrial pressure. Thus the extent of pulmonary hypertension can be estimated. [16],[17]

Additional Tests

Chest Radiography: The following findings are noted:

• Marked cardiomegaly: in severe tricuspid regurgitation
• Pleural effusions and ascites with diaphragmatic elevation
• Pulmonary arterial and venous hypertension common

Serum Chemistry: Abnormal liver function test, hyperbilirubinemia secondary to hepatic congestion may be noted.

Electrocardiography: Nonspecific ST and T waves in the right precordial leads reflecting right ventricular dysfunction seen. If pulmonary hypertension causes tricuspid regurgitation, the ECG may show right axis deviation indicating RV hypertrophy and tall R waves in V1 to V2. In severe pulmonary hypertension, right atrial hypertrophy and "P-pulmonale" may also be present.

Cardiac Catheterization: Elevated end-diastolic pressures in the right atrium and right ventricle are noted.

The preference of treatment depends on the severity of tricuspid regurgitation, etiology, and the presence and the extent of associated abnormalities including pulmonary hypertension, heart failure, and other valve conditions.

Management of severe tricuspid regurgitation includes medical therapy, counseling regarding pregnancy and physical activity, consideration of tricuspid valve surgery, and evaluation and treatment of the underlying cause.

Medical Treatment

In patients with tricuspid regurgitation secondary to left-sided heart failure, adequate control of fluid overload is indicated. Diuretics are suggested in these cases. Loop diuretics are commonly used. Restricted intake of salt is indicated. The head of the bed should be elevated as it may improve dyspnea. Digitalis, potassium-sparing diuretics, angiotensin-converting enzyme inhibitors and anticoagulants are indicated in these patients. Atrial fibrillation, if present, can be controlled by starting the patients on antiarrhythmics.

The following medications are used:

• Diuretics: Furosemide
• Antiarrhythmics
• Digoxin
• Angiotensin-converting enzyme inhibitors
• Anticoagulants

Tricuspid Valve Surgery

Indications for tricuspid valve surgery depend upon whether surgery for left-sided (aortic or mitral) valve disease is indicated

For patients undergoing left-sided valve surgery:

1. Tricuspid valve surgery is recommended in these patients with severe TR, as observed in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) and the 2012 European Society of Cardiology (ESC) valvular disease guidelines [18],[19],[20] 
2. Patients undergoing left-sided valve surgery and who have mild, moderate or severe TR, concomitant tricuspid valve repair is recommended in the following cases:

• Dilation of the tricuspid annulus (transthoracic echocardiogram indicating a diameter of greater than 40 mm or 21 mm/m2 indexed for body surface area or intraoperative diameter greater than 70 mm)
• Previous history of right heart failure. This is a recommendation in the AHA/ACC valve guidelines[21], and similar recommendations are indicated in the 2012 ESC guidelines[22]

Isolated Tricuspid Surgery

The appropriate timing of isolated tricuspid valve surgery is not well established.

In patients who are refractory to medical treatment but have severe tricuspid regurgitation, tricuspid valve surgery is suggested (weak recommendation). It is preferred to perform it before the onset of significant right ventricular dysfunction to control or prevent symptoms, as recommended in the 2014 AHA/ACC valvular guidelines.[21]

In symptomatic and severe isolated tricuspid regurgitation without right ventricular dysfunction, tricuspid valve surgery is strongly recommended as per the 2012 ESC valvular guidelines.[22]

In asymptomatic or minimally symptomatic patients with severe TR, the role of tricuspid valve surgery is ambiguous. The 2014 AHA/ACC valvular guidelines note this uncertainty and include a very weak recommendation that tricuspid valve surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary tricuspid regurgitation and progressive moderate or greater RV dilation and/or systolic dysfunction.[21]. The ESC guidelines view surgery in this setting slightly more favorably and indicate that surgery should be considered in patients with severe isolated tricuspid regurgitation with mild or no symptoms and progressive right ventricular dilation or deterioration of right ventricular function.[22]

Treatment Based on the Etiology

In tricuspid valve endocarditis, it is recommended to excise the tricuspid valve without immediate replacement. The excision of the diseased valve wipes out the endocarditis while the antibiotic treatment is continued. An artificial valve can be inserted if the right heart failure symptoms are refractory to medical management and the infection is well controlled.

In Ebstein anomaly, no surgery is needed in asymptomatic tricuspid regurgitation. However, symptomatic patients may need to be treated with the tricuspid valve repair or replacement.

The differential diagnosis of tricuspid regurgitation are as follows:

• Ascites
• Cirrhosis
• Ebstein anomaly
• Eisenmenger syndrome
• Heart failure
• Marfan syndrome
• Cardiogenic shock
• Atrial fibrillation
• Dilated cardiomyopathy
• Biliary disease
• Cor pulmonale
• Mitral regurgitation
• Carcinoid tumor

Prognosis of tricuspid regurgitation is generally good.

Complications include:

1. Cardiac cirrhosis
2. Ascites
3. Thrombus formation and embolization

Complications of operative interventions include:

1. Heart block
2. Thrombosis of the prosthetic valve
3. Infection
4. Arrhythmias

Further inpatient care of a patient with tricuspid regurgitation involves:

• Anticoagulation may be needed in cases of atrial fibrillation or if the patient has sustained a valve replacement.
• Management of arrhythmias, if present
• Treatment of any infections
• Heart failure

In patients whose valve has been removed, repeat echocardiography is indicated at 6-month intervals. In patients whose valve has been replaced, annual echocardiography is recommended.

The diagnosis and management of tricuspid regurgitation is with an interprofessional team consisting of a cardiologist, cardiac surgeon, internist, primary care provider, and nurse practitioner. The preference of treatment depends on the severity of tricuspid regurgitation, etiology, and the presence and the extent of associated abnormalities including pulmonary hypertension, heart failure, and other valve conditions.

Management of severe tricuspid regurgitation includes medical therapy, counseling regarding pregnancy and physical activity, consideration of tricuspid valve surgery, and evaluation and treatment of the underlying cause. 

Mild cases are usually managed medically but severe cases require open heart surgery. The tricuspid valve can be repaired or replaced depending on the status of the leaflets. Because of the risk of thrombosis, all mechanical valves in the tricuspid position need anticoagulation. Patients need to be monitored for INR regularly. The outcomes of tricuspid regurgitation are usually fair to good. [23](Level V)