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Tricuspid Regurgitation

Background:

Mild Tricuspid regurgitation may be detected in over 90% of the normal population by color Doppler echocardiogram. This is usually a benign finding and does not require any follow up or treatment. Virtually all of the normal population will have a mild degree of leakage in one, two, or three of the heart valves by echocardiogram. We call this physiologic regurgitation and many cardiologists prefer not to mention it to parents, as they may become concerned about a common and benign echocardiogram finding.

Pathologic tricuspid regurgitation is a disorder involving backward flow of blood across the tricuspid valve from the right ventricle (lower heart chamber) to the right atrium (upper heart chamber). Leakage occurs during contraction of the right ventricle and may be caused by damage or malformation of the tricuspid valve or and/or by significant enlargement of the right heart. The tricuspid valve may have been damaged by infection (endocarditis). In other cases, it may be a congenital malformation in the valve itself such as a dysplastic pulmonary valve or Ebstein’s anomaly of the tricuspid valve.

 

Tricuspid regurgitation may also be present in cases of distal anatomic obstructions such as pulmonary valve atresia or in cases of pulmonary hypertension (high pressures in the lungs). Rarely it may be caused by an unusual tumor called a carcinoid, rheumatoid arthritis, radiation therapy, Marfan’s syndrome, or chest trauma. Finally, tricuspid regurgitation is found in many patients with a single ventricle, corrected transposition of the great arteries or those who underwent the Fontan procedure in which the right ventricle is acting as the main pump of the heart. Those patients require lifetime follow up with serial echocardiograms. The tricuspid regurgitation may become severe enough to require heart surgery.

 

Other potential causes of significant tricuspid regurgitation include restrictive cardiomyopathy and constrictive pericarditis.

 

Symptoms:

Mild to moderate tricuspid regurgitation may not produce any symptoms at all in patients with normal pulmonary pressures. Patients with pulmonary hypertension and/or severe tricuspid regurgitation may experience these symptoms:

 

Fatigue, tiredness

Weakness

Difficulty breathing

Shortness of breath, especially on exertion

General swelling

Swelling of the abdomen

Swelling of the feet and ankles

Active pulsing in the neck veins

Palpitations or “racing heart”

Weight loss

Loss of appetite

Heart failure

 

Diagnosis and Cardiovascular Tests:

In cases of mild tricuspid regurgitation, the physical examination may be completely normal without an audible heart murmur. In cases of moderate severe tricuspid regurgitation, a heart murmur may be present and the liver may be enlarged. The abdomen may be distended and edema (swollen extremities) may be present. The electrocardiogram and chest x-ray may be abnormal. The echocardiogram is very helpful in determining the degree of tricuspid regurgitation, the size of the right heart, and its function. In addition, it may show the veins draining into the heart as being dilated. An echo may show any malformation or damage to the tricuspid valve or if an associated heart defect is present. Doppler echocardiography is used to estimate the pressures inside the heart and lungs. In more severe cases, the patient may require an MRI or cardiac catheterization.

 

Treatment:

Most patients with mild tricuspid regurgitation will not require any medical treatment. Patients with a normal heart and very mild forms of tricuspid regurgitation do not require any follow up. In more severe cases, the patients may require diuretics (water pills), while other patients may benefit from other medications that help improve the contractility of the heart. Medical treatment may depend on the underlying condition. For example, patients with pulmonary hypertension may require specific medications to lower lung pressures.

 

In general, patients with a single ventricle and the Fontan procedure may be on a few medications that may help release some of the volume overload or workload of the right ventricle and others may help improve the contractility of the heart pump.

 

Patients with an anatomical or structural problem of the tricuspid valve may require heart surgery. Some patients with progressive tricuspid regurgitation may also require surgery to prevent further deterioration of heart function.

 

Outcome:

Patients with an otherwise normal heart and mild to moderate tricuspid regurgitation lead a normal life and have no restrictions. Most of the restrictions to sports are associated with an underlying associated heart defect or underlying condition such as pulmonary hypertension. Therefore, prognosis in general may depend on the underlying condition and potential risk factors and not as much on the severity of the tricuspid regurgitation. Long-term complications may include heart failure, endocarditis, weight loss, and liver damage (cirrhosis).

 

Patients who plan to participate in competitive sports or become pregnant should consult in advance with Dr. Villafañe.

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