Tricuspid insufficiency

Tricuspid insufficiency
Tricuspid regurgitation
Classification and external resources
Specialty Cardiology
ICD-10 I07.1, I36.1, Q22.8
ICD-9-CM 397.0
MedlinePlus 000169
eMedicine med/2314
MeSH D014262

Tricuspid insufficiency (TI), a valvular heart disease also called tricuspid regurgitation (TR), refers to the failure of the heart's tricuspid valve to close properly during systole. This defect allows the blood to flow backwards, reducing its efficiency.[1] Regurgitation may be due to a structural change of components of the tricuspid valve apparatus, a lesion can be primary (intrinsic abnormality) or secondary (right ventricular dilatation).[2]

Signs and symptoms

Signs/symptoms of tricuspid insufficiency are generally those of right-sided heart failure, such as ascites and peripheral edema.[2]

Tricuspid insufficiency may lead to the presence of a pansystolic heart murmur. Such a murmur is usually of low frequency and best heard low on the lower left sternal border. As with most right-sided phenomena, it tends to increase with inspiration, and decrease with expiration.However, the murmur may be inaudible indicating the relatively low pressures in the right side of the heart. A third heart sound may also be present, also heard with inspiration at the lower sternal border.[3][4]

In addition to the possible ausculatory findings above, there are other signs indicating the presence of tricuspid regurgitation. There may be giant C-V waves in the jugular pulse[5] and a palpably (and sometimes visibly) pulsatile liver on abdominal exam. Since the murmur of tricupsid regurgitation may be faint or inaudible, these signs can be helpful in establishing the diagnosis.[6]

Causes

The causes of tricuspid insufficiency can be congenital in origin.[7] Much more common than a congenital abnormality of the valve, however, is right ventricular dilatation of any cause. Such dilatation is most often the result left heart failure (of any cause) or pulmonary hypertension. Dilation leads to derangement of the normal anatomy and mechanics of the tricuspid valve and the muscles governing its proper function, with the result being incompetence of the tricuspid valve. Other common causes of right ventricular dilation include right ventricular infarction, inferior myocardial infarction, and cor pulmonale.

Endocarditis

In regards to primary and secondary causes they are:[8]

Mechanism

In terms of the mechanism of tricuspid insufficiency it involves the expansion of the tricuspid annulus(fibrous rings of heart). Tricuspid insufficiency is linked to geometry changes of the tricuspid annulus ( decreased tricuspid annular release). The leaflets shape are normal but prevented from normal working mechanism due to a distortion of spatial relationships of leaflets and chords.[9] It is also contemplated that the process via which tricuspid regurgitation emerges, is a decrease of contraction of the myocardium around the annulus,[10]

Diagnosis

In the diagnosis of tricuspid insufficiency a chest x-ray will demonstrate right heart enlargement. An echocardiogram will assess the chambers of the heart, as well as, right ventricular pressure. Cardiac magnetic resonance may also be used as a diagnostic tool, and finally, cardiac catheterization may determine the extent of the regurgitation.[3]

Management

ACE inhibitor

In terms of treatment for tricuspid insufficiency prosthetic valve substitutes can be used, though artificial prostheses may cause thrombo‐embolic phenomena(bioprostheses may have a degeneration problem).[10] Some evidence suggests that there are no significant differences between a mechanical or biological tricuspid valve in a recipient.[11]

Generally, surgical treatment of tricuspid regurgitation is not indicated when it has arisen as a result of right ventricular dilatation. In such instances of secondary tricuspid regurgitation, the mainstay of therapy is medical. When left-sided heart failure is the cause, the individual is instructed to decrease intake of salt. Medications in this case may include diuretics and angiotensin-converting enzyme inhibitors.[12]

Prognosis

The prognosis of tricuspid insufficiency is less favorable for males than females. Furthermore, increased tricuspid insufficiency (regurgitation) severity is an indication of a poorer prognosis according to Nath, et al.[13] It is also important to note that since tricuspid insufficiency most often arises from left heart failure or pulmonary hypertension, the person's prognosis is usually dictated by the prognosis of the latter conditions and not by the tricuspid insufficiency per se.

References

  1. ↑ "Tricuspid regurgitation: MedlinePlus Medical Encyclopedia". www.nlm.nih.gov. Retrieved 2015-12-14.
  2. 1 2 "Tricuspid Regurgitation Clinical Presentation: History, Physical Examination". emedicine.medscape.com. Retrieved 2015-12-14.
  3. 1 2 "Tricuspid Valve Disease & Tricuspid regurgitation (TR) | Patient". Patient. Retrieved 2015-12-14.
  4. ↑ Berg, Dale; Worzala, Katherine (2006-01-01). Atlas of Adult Physical Diagnosis. Lippincott Williams & Wilkins. p. 90. ISBN 9780781741903.
  5. ↑ http://www.nejm.org/doi/full/10.1056/NEJMicm1103312
  6. ↑ "http://bestpractice.bmj.com/best-practice/monograph/472/diagnosis.html"
  7. ↑ Samed, Said (2014). "Management of tricuspid regurgitation in congenital heart disease: Is survival better with valve repair?". Journal of Thoracic and Cardiovascular surgery. Retrieved 15 December 2015.
  8. ↑ Rogers, Jason H.; Bolling, Steven F. (2009-05-26). "The Tricuspid Valve Current Perspective and Evolving Management of Tricuspid Regurgitation". Circulation. 119 (20): 2718–2725. doi:10.1161/CIRCULATIONAHA.108.842773. ISSN 0009-7322. PMID 19470900.
  9. ↑ Hung, Judy (2010-01-01). "The Pathogenesis of Functional Tricuspid Regurgitation". Seminars in Thoracic and Cardiovascular Surgery. Emerging Treatment of Stage I Non-Small Cell Lung Cancer Edited by Arjun Pennathur, MD; Functional Tricuspid Regurgitation Edited by Ani C. Anyanwu, MSc, MD, FRCS. 22 (1): 76–78. doi:10.1053/j.semtcvs.2010.05.004. – via ScienceDirect (Subscription may be required or content may be available in libraries.)
  10. 1 2 Antunes, Manuel J; Barlow, John B (2007-02-01). "Management of tricuspid valve regurgitation". Heart. 93 (2): 271–276. doi:10.1136/hrt.2006.095281. ISSN 1355-6037. PMC 1861404Freely accessible. PMID 17228081.
  11. ↑ "BestBets: Should the tricuspid valve be replaced with a mechanical or biological valve?". www.bestbets.org. Retrieved 2015-12-14.
  12. ↑ "Tricuspid Regurgitation Treatment & Management: Approach Considerations, Medical Therapy, Surgical Care".
  13. ↑ "Impact of tricuspid regurgitation on long-term survival". content.onlinejacc.org. Retrieved 2015-12-14.

Further reading

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