| disease | Tricuspid Valve Insufficiency |
| alias | Tricuspid Insufficiency |
Tricuspid insufficiency is rarely caused by the involvement of the valve leaflets themselves, but is more often due to pulmonary hypertension and tricuspid valve dilation. It is commonly seen in significant mitral valve disease and chronic lung heart disease.
bubble_chart Etiology
Tricuspid regurgitation is often caused by pulmonary {|###|} hypertension and tricuspid valve dilation. It is commonly seen in significant mitral valve disease and chronic {|###|} lung heart disease, inferior wall myocardial infarction involving the right ventricle, heart failure in the advanced stage caused by {|###|} wind-dampness or congenital heart disease with pulmonary {|###|} hypertension, ischemic heart disease, and cardiomyopathy. Rare causes include {|###|} wind-dampness-induced tricuspid valve inflammation leading to shortening and deformation of the valve membrane, often combined with tricuspid stenosis; congenital Ebstein's anomaly; valve membrane damage caused by infective endocarditis; tricuspid valve prolapse, which is often accompanied by mitral valve prolapse and commonly seen in Marfan syndrome; and it can also occur in right atrial myxoma, right ventricular myocardial infarction, and after chest trauma.
Acquired isolated tricuspid regurgitation can occur in carcinoid syndrome, as carcinoid patches often deposit on the ventricular side of the tricuspid valve and cause adhesion between the valve leaflets and the right ventricular wall, leading to tricuspid regurgitation. These patients often also have pulmonary {|###|} valve disease. In cases of tricuspid regurgitation, there is often significant enlargement of the right heart.
bubble_chart Clinical Manifestations
Tricuspid valve insufficiency causes pathophysiological changes in the right side of the heart similar to the effects of mitral valve insufficiency on the left side of the heart, but the compensatory period is longer; if the condition gradually progresses, it can eventually lead to hypertrophy of the right ventricle and right atrium, and right ventricular failure. In cases of significant pulmonary stirred pulse hypertension, the condition progresses more rapidly.(1) Symptoms: When tricuspid valve insufficiency is combined with pulmonary stirred pulse hypertension, symptoms of reduced cardiac output and systemic congestion may occur. In cases where tricuspid valve insufficiency is combined with mitral valve disease, the symptoms of pulmonary congestion may be alleviated due to the progression of tricuspid valve insufficiency, but lack of strength and other symptoms of reduced cardiac output may become more severe.
(2) Signs: The main sign is a pansystolic murmur at the lower left sternal border, which may intensify upon inspiration and after liver compression; however, if the failing right ventricle cannot increase stroke volume, the murmur may not intensify. Only when the flow is very large, a third heart sound and a low-pitched diastolic intermediate stage [second stage] murmur in the tricuspid area may be present. The v wave (also known as the regurgitant wave, caused by blood flowing back into the large veins of the right atrium during right ventricular contraction) on the jugular venous pulse wave diagram increases; liver pulsation may be palpable. When the valve membrane prolapses, a non-ejection click may be heard in the tricuspid area. The signs of congestion are the same as those of right heart failure.
(1) X-ray examination: Enlargement of the right ventricle and right atrium can be observed. In cases with elevated right atrial pressure, dilation of the azygos vein and pleural effusion may be seen; in cases with ascites, the diaphragm is elevated. Right atrial systolic pulsation can be observed during fluoroscopy.
(2) Electrocardiogram (ECG) examination: May show right ventricular hypertrophy and strain, right atrial enlargement; and often right bundle branch block.
(3) Echocardiographic examination: Enlargement of the right ventricle and right atrium, dilation and pulsation of the superior and inferior vena cava; and flail tricuspid valve can be observed. Two-dimensional echocardiographic contrast can confirm regurgitation, and Doppler ultrasound can assess the degree of regurgitation and pulmonary artery hypertension.
Based on typical murmurs, enlargement of the right ventricle and right atrium, and symptoms and signs of systemic congestion, the diagnosis is generally not difficult to make. Echocardiography with contrast and Doppler ultrasound can confirm the diagnosis and help determine the cause of the disease.
bubble_chart Treatment Measures
Isolated tricuspid regurgitation without pulmonary hypertension, such as that secondary to infective endocarditis or trauma, generally does not require surgical treatment. Active treatment of heart failure caused by other factors can improve the severity of functional tricuspid regurgitation. In cases of mitral valve disease accompanied by pulmonary hypertension and significant right ventricular enlargement, correcting the mitral valve abnormality and reducing pulmonary pressure can gradually alleviate or eliminate tricuspid regurgitation without the need for specific treatment. For severe organic tricuspid valve disease, especially rheumatic cases without severe pulmonary hypertension, annuloplasty or artificial heart valve replacement may be performed.
It should be differentiated from mitral insufficiency and low ventricular septal defect.
Mitral insufficiency: A typical blowing systolic murmur in the apex area with enlargement of the left atrium and left ventricle.
Tricuspid insufficiency: A localized blowing holosystolic murmur is heard at the lower left sternal border, which increases with inspiration due to increased venous return and decreases with expiration. In pulmonary hypertension, the second heart sound of the pulmonary valve is accentuated, and the jugular venous v wave is enlarged. There may be liver pulsation and enlargement. Right ventricular hypertrophy can be seen on electrocardiogram and X-ray. Echocardiography can confirm the diagnosis.
