Tricuspid Regurgitation

Cardiovascular

Clinicals - History

Fact Explanation
Fatigue and exercise intolerance Tricuspid Regurgitation(TR) can occur according to the following mechanisms: secondary to pulmonary hypertension, anatomical abnormalities. In a patient with pulmonary hypertension, the walls of pulmonary vasculature becomes thicker. The resistance to the flow is increased.During exercise,inadequate pulmonary circulation results in hypoxia.This reduces aerobic metabolism in the tissues and the patient describes this as fatigue.In an isolated tricuspid regurgitation due to anatomical defect, above symptoms are due to reduced right sided cardiac output to the pulmonary circulation. Fatigue and exercise intolerance
Tricuspid Regurgitation(TR) can occur according to the following mechanisms: secondary to pulmonary hypertension, anatomical abnormalities. In a patient with pulmonary hypertension, the walls of pulmonary vasculature becomes thicker. The resistance to the flow is increased.During exercise,inadequate pulmonary circulation results in hypoxia.This reduces aerobic metabolism in the tissues and the patient describes this as fatigue.In an isolated tricuspid regurgitation due to anatomical defect, above symptoms are due to reduced right sided cardiac output to the pulmonary circulation.
Dyspnoea Dyspnoea is defined as labored breathing.This is due to hypoxia resulted by restricted pulmonary circulation,that creates a ventilation perfusion mismatch.Hypoxia stimulates respiratory center in medulla oblongata, increasing the rate and respiratory effort. Dyspnoea
Dyspnoea is defined as labored breathing.This is due to hypoxia resulted by restricted pulmonary circulation,that creates a ventilation perfusion mismatch.Hypoxia stimulates respiratory center in medulla oblongata, increasing the rate and respiratory effort.
Palpitations This is related to atrial arrhythmias ( atrial fibrillation/flutter).These arrhythmias are secondary to alteration in conduction circuits in atrial walls that occurs due to atrial dilation.
There are two mechanisms which may result in this: conditions such as mitral stenosis gives rise to both left atrial dilation and pulmonary hypertension(secondary tricuspid regurgitation, the regurgitant flow of blood can dilate right atrium.
Palpitations
This is related to atrial arrhythmias ( atrial fibrillation/flutter).These arrhythmias are secondary to alteration in conduction circuits in atrial walls that occurs due to atrial dilation.
There are two mechanisms which may result in this: conditions such as mitral stenosis gives rise to both left atrial dilation and pulmonary hypertension(secondary tricuspid regurgitation, the regurgitant flow of blood can dilate right atrium.
Peripheral edema This can manifest as ankle edema or hydrocele.In tricuspid regurgitation, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at the venular end increases and transudation occurs. Peripheral edema
This can manifest as ankle edema or hydrocele.In tricuspid regurgitation, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at the venular end increases and transudation occurs.
Abdominal distension Ascites can present as abdominal distension as a result of chronic severe TR which is from chronic congestion or fibrosis of liver (cardiac cirrhosis) resulting from reduced cardiac output from right-sided heart failure. Abdominal distension
Ascites can present as abdominal distension as a result of chronic severe TR which is from chronic congestion or fibrosis of liver (cardiac cirrhosis) resulting from reduced cardiac output from right-sided heart failure.
Early satiety, dyspepsia, or indigestion Symptoms are due to congestion and resultant transudation in the stomach and intestinal walls. Early satiety, dyspepsia, or indigestion
Symptoms are due to congestion and resultant transudation in the stomach and intestinal walls.
Right hypochondrial pain Transudate accumulates beneath the hepatic capsule.Stretching of the capsule which is pain sensitive, causes pain. Right hypochondrial pain
Transudate accumulates beneath the hepatic capsule.Stretching of the capsule which is pain sensitive, causes pain.
History of a aetiology in secondary TR. Pathological TR is often secondary.The annular dilatation and increased leaflet tethering are the results of pressure or volume overload.Pressure overload is due to left sided heart diseases or cor pulmonale. Volume overload is due to intrinsic valve disease or an atrial septal defect. History of a aetiology in secondary TR.
Pathological TR is often secondary.The annular dilatation and increased leaflet tethering are the results of pressure or volume overload.Pressure overload is due to left sided heart diseases or cor pulmonale. Volume overload is due to intrinsic valve disease or an atrial septal defect.

Clinicals - Examination

Fact Explanation
Pulse- Rhythm Regular or Irregularly irregular This is due to atrial arrhythmias ( atrial fibrilation/flutter).These Arrhythmias are secondary to alteration in conduction circuits in atrial walls that are results of atrial dilation.
The mechanisms of this phenomenon are: conditions such as mitral stenosis gives rise to both left atrial dilation and pulmonary hypertension(secondary tricuspid regurgitation, the regurgitant flow of blood can dilate right atrium.
Pulse- Rhythm Regular or Irregularly irregular
This is due to atrial arrhythmias ( atrial fibrilation/flutter).These Arrhythmias are secondary to alteration in conduction circuits in atrial walls that are results of atrial dilation.
The mechanisms of this phenomenon are: conditions such as mitral stenosis gives rise to both left atrial dilation and pulmonary hypertension(secondary tricuspid regurgitation, the regurgitant flow of blood can dilate right atrium.
Peripheral edema(ankle edema,hydrocele) In TR, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at the venular end increases(Starling's Forces) and transudation occurs. Peripheral edema(ankle edema,hydrocele)
In TR, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at the venular end increases(Starling's Forces) and transudation occurs.
Elevated jugular venous pressure with a prominent 'c and v' Waves. The 'c' wave occurs as the right ventricular systolic pressure is transmitted to right atrium before the closure of tricuspid valve. Then backward pressure wave is transmitted along the internal jugular vein. The 'v' wave occurs during the venous return to right atrium.There is a regurgitant flow due to TR that increase the total volume in the right atrium.This becomes a vicious cycle that leads to dilation of the right atrium.Eventually the backward pressure wave is transmitted along the internal jugular vein. Elevated jugular venous pressure with a prominent 'c and v' Waves.
The 'c' wave occurs as the right ventricular systolic pressure is transmitted to right atrium before the closure of tricuspid valve. Then backward pressure wave is transmitted along the internal jugular vein. The 'v' wave occurs during the venous return to right atrium.There is a regurgitant flow due to TR that increase the total volume in the right atrium.This becomes a vicious cycle that leads to dilation of the right atrium.Eventually the backward pressure wave is transmitted along the internal jugular vein.
Precordial bulging In a patient with pulmonary hypertension (due to either a cardiac or pulmonary cause), the resistance in the pulmonary circulation causes right ventricular hypertrophy. With time changes in shape of the thoracic wall can be observed. Precordial bulging
In a patient with pulmonary hypertension (due to either a cardiac or pulmonary cause), the resistance in the pulmonary circulation causes right ventricular hypertrophy. With time changes in shape of the thoracic wall can be observed.
Para sternal heave The hypertrophied right ventricle creates pressure on the precordium, that is palpated in the form of para sternal heave. Para sternal heave
The hypertrophied right ventricle creates pressure on the precordium, that is palpated in the form of para sternal heave.
Pan systolic murmur at left lower sternum which increases in intensity on inspiration. (Carvallo’s sign). The murmur is generated by turbulent flow. In TR increased blood flow and regurgitation across the tricuspid valve causes the turbulence of flow.,,,, Pan systolic murmur at left lower sternum which increases in intensity on inspiration. (Carvallo’s sign).
The murmur is generated by turbulent flow. In TR increased blood flow and regurgitation across the tricuspid valve causes the turbulence of flow.,,,,
Third heart sound (S3) A third heart sound (S3) is heard in rapid ventricular filling.Due to the regurgitant flow, there is an increase the total volume in the right atrium.The increased volume produces S3.This is common in patients with heart failure. Third heart sound (S3)
A third heart sound (S3) is heard in rapid ventricular filling.Due to the regurgitant flow, there is an increase the total volume in the right atrium.The increased volume produces S3.This is common in patients with heart failure.
Loud second heart sound in the pulmonary area (P2) This is audible in patients with pulmonary hypertension. Loud second heart sound in the pulmonary area (P2)
This is audible in patients with pulmonary hypertension.
Pulsatile, tender hepatomegaly In Tricuspid Regurgitation, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at venular end increases and transudation occurs.The transudate accumulates and stretches the pain sensitive hepatic capsule.
The back pressure causes congestion of blood in hepatic venous system.This also contributes to the hepatomegaly.
Pulsatile, tender hepatomegaly
In Tricuspid Regurgitation, the increased pressure (due to regurgitant flow) in right atrium is transmitted back to venous system(Inferior vena cava).The pressure gradient at venular end increases and transudation occurs.The transudate accumulates and stretches the pain sensitive hepatic capsule.
The back pressure causes congestion of blood in hepatic venous system.This also contributes to the hepatomegaly.
Ascitis Ascites can present as abdominal distension as a result of chronic severe TR which is from chronic congestion or fibrosis of liver (cardiac cirrhosis) resulting from reduced cardiac output from right-sided heart failure., Ascitis
Ascites can present as abdominal distension as a result of chronic severe TR which is from chronic congestion or fibrosis of liver (cardiac cirrhosis) resulting from reduced cardiac output from right-sided heart failure.,
Signs of aetiology in secondary TR Pathological TR is often secondary.The annular dilatation and increased leaflet tethering are the results of pressure or volume overload. Pressure overload is due to left sided heart diseases such as mitral stenosis or cor pulmonale. Volume overload is due to intrinsic valve disease or atrial septal defects. Signs of aetiology in secondary TR
Pathological TR is often secondary.The annular dilatation and increased leaflet tethering are the results of pressure or volume overload. Pressure overload is due to left sided heart diseases such as mitral stenosis or cor pulmonale. Volume overload is due to intrinsic valve disease or atrial septal defects.

Investigations - Diagnosis

Fact Explanation
Trans thoracic echocardiography(2D/3D) and color flow doppler. Done in order to differentiate the causes (primary and secondary causes by observing structural abnormalities),asses the degree of dilation of annulus which is used to grade the severity together with pulmonary systolic pressure. ,, Trans esophageal echocardiography (TOE) should be considered when trans thoracic echocardiography (TTE) is of suboptimal quality or when thrombosis, prosthetic dysfunction, or endocarditis
is suspected.
Trans thoracic echocardiography(2D/3D) and color flow doppler.
Done in order to differentiate the causes (primary and secondary causes by observing structural abnormalities),asses the degree of dilation of annulus which is used to grade the severity together with pulmonary systolic pressure. ,, Trans esophageal echocardiography (TOE) should be considered when trans thoracic echocardiography (TTE) is of suboptimal quality or when thrombosis, prosthetic dysfunction, or endocarditis
is suspected.
Cardiac magnetic resonance When echocardiographic imaging is suboptimal and investigation of choice in assessing a patient with severe TR or to asses other right ventricular parameters., Cardiac magnetic resonance
When echocardiographic imaging is suboptimal and investigation of choice in assessing a patient with severe TR or to asses other right ventricular parameters.,
Cardiac catheterisation This invasive procedure is only used when non invasive investigation data are suboptimal. Also this technique is used in accurate measurement of pulmonary artery pressure and pulmonary vascular resistance to identify a cause for pulmonary hypertension., Cardiac catheterisation
This invasive procedure is only used when non invasive investigation data are suboptimal. Also this technique is used in accurate measurement of pulmonary artery pressure and pulmonary vascular resistance to identify a cause for pulmonary hypertension.,
Chest X-Ray This investigation indicates cardiomegaly and supports the diagnosis of pulmonary hypertension. Chest X-Ray
This investigation indicates cardiomegaly and supports the diagnosis of pulmonary hypertension.
ElectroCardiogram (ECG/EKG) This is used to conform rhythm abnormalities(atrial fibrillation). It also provides additional information to suggest complications such as right bundle branch block to suggest right ventricular hypertrophy. ElectroCardiogram (ECG/EKG)
This is used to conform rhythm abnormalities(atrial fibrillation). It also provides additional information to suggest complications such as right bundle branch block to suggest right ventricular hypertrophy.

Investigations - Management

Fact Explanation
Echocardiography (2D/3D) with color flow doppler. This is a non invasive, accurate and commonly performed. Echocardiography (2D/3D) with color flow doppler.
This is a non invasive, accurate and commonly performed.
Trans esophageal echocardiography Should be considered when thrombosis or endocarditis is suspected. Trans esophageal echocardiography
Should be considered when thrombosis or endocarditis is suspected.
Exercise ECG The purpose is to further assess asymptomatic patients or those with doubtful symptoms. Exercise testing will also determine the level of physical activity allowed. Exercise ECG
The purpose is to further assess asymptomatic patients or those with doubtful symptoms. Exercise testing will also determine the level of physical activity allowed.
Exercise echocardiography Exercise echocardiography may provide additional information regarding the functional state in exertion. Exercise echocardiography
Exercise echocardiography may provide additional information regarding the functional state in exertion.

Management - Supportive

Fact Explanation
Patient Education Patients should understand how to monitor
their symptoms, weight fluctuation and restrict their sodium intake, have good compliance on medication and stay physically active. Education regarding these recommendations can significantly improve outcomes
Patient Education
Patients should understand how to monitor
their symptoms, weight fluctuation and restrict their sodium intake, have good compliance on medication and stay physically active. Education regarding these recommendations can significantly improve outcomes
Restriction of dietary Sodium. Observational study data suggest an association between dietary sodium intake with fluid retention and risk for hospitalization. The sodium homeostasis is altered in patients with HF as opposed to healthy individuals so restriction of dietary sodium is important. Restriction of dietary Sodium.
Observational study data suggest an association between dietary sodium intake with fluid retention and risk for hospitalization. The sodium homeostasis is altered in patients with HF as opposed to healthy individuals so restriction of dietary sodium is important.
Activity, Exercise Prescription, and Cardiac Rehabilitation Exercise training (or regular physical activity) is recommended. Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, mortality Activity, Exercise Prescription, and Cardiac Rehabilitation
Exercise training (or regular physical activity) is recommended. Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, mortality

Management - Specific

Fact Explanation
Diuretics Following are commonly used diuretics in managing symptomatic patients. Bumetanide, furosemide, and torsemide inhibit Na+ absorption in thick ascending limb of the loop of Henle (thus, the term loop diuretics) and they are the more preferred group. Thiazides inhibit transport of Na+ in Proximal Convoluted Tubules(PCT). Aldesterone receptor antagonists such as spironolactone antagonize the effect of Aldesterone at the collecting tubules. Sodium is the significant osmotically active ion that retains water. These drugs increase urinary sodium excretion and decrease physical signs of fluid retention in patients with heart failure. Diuretics
Following are commonly used diuretics in managing symptomatic patients. Bumetanide, furosemide, and torsemide inhibit Na+ absorption in thick ascending limb of the loop of Henle (thus, the term loop diuretics) and they are the more preferred group. Thiazides inhibit transport of Na+ in Proximal Convoluted Tubules(PCT). Aldesterone receptor antagonists such as spironolactone antagonize the effect of Aldesterone at the collecting tubules. Sodium is the significant osmotically active ion that retains water. These drugs increase urinary sodium excretion and decrease physical signs of fluid retention in patients with heart failure.
Angiotensin Converting Enzyme Inhibitors (ACEI) Drugs such as Captopril or Enalapril inhibit the conversion of angiotensin I to angiotensin II.It reduces the effect of angiotensin II and there by produce vasodilation, reduce peripheral resistance and reduces afterload. It also reduces Aldesterone secretion and eventually reduce salt and water retention. ACEI reduce morbidity and mortality in heart failure. Angiotensin Converting Enzyme Inhibitors (ACEI)
Drugs such as Captopril or Enalapril inhibit the conversion of angiotensin I to angiotensin II.It reduces the effect of angiotensin II and there by produce vasodilation, reduce peripheral resistance and reduces afterload. It also reduces Aldesterone secretion and eventually reduce salt and water retention. ACEI reduce morbidity and mortality in heart failure.
Angiotensin Receptor Blockers (ARB) They inhibit the action of angiotensin II on AT1 receptors found on the vasculature.The effect is similar to that of ACEI these are used as an alternative to ACEI in patients intolerant to ACEIs. Angiotensin Receptor Blockers (ARB)
They inhibit the action of angiotensin II on AT1 receptors found on the vasculature.The effect is similar to that of ACEI these are used as an alternative to ACEI in patients intolerant to ACEIs.
Beta Blockers (bisoprolol, carvedilol, and sustained release metoprolol succinate) These drugs competitively inhibit the action of catecholamines on beta receptors on the myocardium exerting a negative inotropic effect.These are a prognostically beneficial class of drugs. Beta Blockers (bisoprolol, carvedilol, and sustained release metoprolol succinate)
These drugs competitively inhibit the action of catecholamines on beta receptors on the myocardium exerting a negative inotropic effect.These are a prognostically beneficial class of drugs.
Digoxin Used treat atrial fibrillation. This cardiac glycoside increases the intracellular free calcium level and increase contractility and reduces heart rate.This is only beneficial symptomatically. Digoxin
Used treat atrial fibrillation. This cardiac glycoside increases the intracellular free calcium level and increase contractility and reduces heart rate.This is only beneficial symptomatically.
Anticoagulants The selection of an anticoagulant agent for permanent/persistent/paroxysmal AF should be individualized.The action of Warfarin is that,it blocks gamma carboxylation of glutamate residues of clotting factors II, VII, IX and X. This means that they stay in an inactive form. This is used in the treatment of chronic atrial fibrillation. Anticoagulants
The selection of an anticoagulant agent for permanent/persistent/paroxysmal AF should be individualized.The action of Warfarin is that,it blocks gamma carboxylation of glutamate residues of clotting factors II, VII, IX and X. This means that they stay in an inactive form. This is used in the treatment of chronic atrial fibrillation.
Sildenafil Causes vasodilation in pulmonary vasculature in patients with pulmonary hypertension and relives dyspnoea. However the precipitant cause must be managed optimally. Sildenafil
Causes vasodilation in pulmonary vasculature in patients with pulmonary hypertension and relives dyspnoea. However the precipitant cause must be managed optimally.
Surgical valve replacement Surgery is indicated in patients with severe TR. If it is technically feasible valve repair is preferable to valve replacement and surgery should be carried out early enough to avoid irreversible right ventricular dysfunction.
Surgery limited to the tricuspid valve is recommended in symptomatic patients with severe primary TR. Though these patients
respond well to diuretic therapy, delaying surgery is likely to result in irreversible RV damage, organ failure. ,
Surgical valve replacement
Surgery is indicated in patients with severe TR. If it is technically feasible valve repair is preferable to valve replacement and surgery should be carried out early enough to avoid irreversible right ventricular dysfunction.
Surgery limited to the tricuspid valve is recommended in symptomatic patients with severe primary TR. Though these patients
respond well to diuretic therapy, delaying surgery is likely to result in irreversible RV damage, organ failure. ,
Endocarditis Prophylaxis Antibiotic prophylaxis should be considered for high-risk procedures in high-risk patients such as those with prosthetic heart valves or patients with previous endocarditis. Endocarditis Prophylaxis
Antibiotic prophylaxis should be considered for high-risk procedures in high-risk patients such as those with prosthetic heart valves or patients with previous endocarditis.

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