Tricuspid insufficiency
Encyclopedia
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
. As a result, with each heart beat some blood passes from the right ventricle
to the right atrium
, the opposite of the normal direction. Tricuspid regurgitation occurs in roughly less than 1% of people and is usually asymptomatic.
. Such dilation leads to derangement of the normal anatomy and mechanics of the tricuspid valve and the muscles governing its proper function. The result is incompetence of the tricuspid valve. Left ventricular failure is, in turn, the most common cause of right ventricular dilation. Other common causes of right ventricular dilation include right ventricular infarction, inferior myocardial infarction and cor pulmonale
.
Other diseases can directly affect the tricuspid valve. The most common of these is rheumatic fever
, which is a complication of untreated strep throat infections. It is usually accompanied by mitral and aortic valvular disease
. Another condition directly harming the valve is tricuspid endocarditis
.
It may be found in those with a type of congenital heart disease called Ebstein's anomaly
.
Other infrequent causes of tricuspid regurgitation include:
Another important risk factor for tricuspid regurgitation is use of the diet medications called "Fen-Phen
" (phentermine and fenfluramine) or dexfenfluramine
Tricuspid insufficiency may be asymptomatic, especially if right ventricular function is well preserved. Symptoms are generally those of right-sided heart failure, such as ascites
, hepatomegaly
, edema
and jugular venous distension Vague upper abdominal discomfort (from a congested liver), and fatigue (due to diminished cardiac output
) can all be present to some degree.
Signs
On examination, the jugular venous pressure
is usually elevated, and 'CV' waves can be seen. It features prominent V waves and rapid y descents in jugular venous pressure
The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency). Peripheral edema is often found. In severe cases, there may be ascites
and even cirrhosis
(so-called 'cardiac cirrhosis').
Triscuspid 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. It tends to increase with inspiration, and decrease with expiration and Valsalva maneuver
. However, the murmur may be inaudible reflecting the relatively low pressures in the right side of the heart. A third heart sound
may also be present, also heard best with inspiration at the left lower sternal border. Parasternal heave
may be felt along the left lower sternal border as well.
Atrial fibrillation
is usually present.
Electrocardiography assists in the diagnosis, indicating enlargement of right ventricle and atrium.
. Medical therapy with diuretics is the mainstay of treatment. Unfortunately, this can lead to volume depletion and decreased cardiac output
. Indeed, one must often accept a certain degree of symptomatic tricuspid insufficiency in order to prevent a decrease in cardiac output. Treatment with medicines to reduce cardiac afterload
may also be of benefit but a similar risk of depressed cardiac output applies.
Where surgery has to be performed, the following alternatives are available:
Valvular heart disease
Valvular heart disease is any disease process involving one or more of the valves of the heart . Valve problems may be congenital or acquired...
also called tricuspid regurgitation (TR), refers to the failure of the heart's tricuspid valve
Tricuspid valve
The tricuspid valve, or right atrioventricular valve, is on the right dorsal side of the mammalian heart, between the right atrium and the right ventricle. The normal tricuspid valve usually has three leaflets and three papillary muscles. They are connected to the papillary muscles by the chordae...
to close properly during systole
Systole (medicine)
Systole is the contraction of the heart. Used alone, it usually means the contraction of the left ventricle.In all mammals, the heart has 4 chambers. The left and right ventricles pump together. The atria and ventricles pump in sequence...
. As a result, with each heart beat some blood passes from the right ventricle
Right ventricle
The right ventricle is one of four chambers in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk....
to the right atrium
Right atrium
The right atrium is one of four chambers in the hearts of mammals and archosaurs...
, the opposite of the normal direction. Tricuspid regurgitation occurs in roughly less than 1% of people and is usually asymptomatic.
Causes
Although congenital causes of tricuspid insufficiency exist, most cases are due to dilation of the right ventricleRight ventricle
The right ventricle is one of four chambers in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk....
. Such dilation leads to derangement of the normal anatomy and mechanics of the tricuspid valve and the muscles governing its proper function. The result is incompetence of the tricuspid valve. Left ventricular failure is, in turn, the most common cause of right ventricular dilation. Other common causes of right ventricular dilation include right ventricular infarction, inferior myocardial infarction and cor pulmonale
Cor pulmonale
Cor pulmonale or pulmonary heart disease is enlargement of the right ventricle of the heart as a response to increased resistance or high blood pressure in the lungs ....
.
Other diseases can directly affect the tricuspid valve. The most common of these is rheumatic fever
Rheumatic fever
Rheumatic fever is an inflammatory disease that occurs following a Streptococcus pyogenes infection, such as strep throat or scarlet fever. Believed to be caused by antibody cross-reactivity that can involve the heart, joints, skin, and brain, the illness typically develops two to three weeks after...
, which is a complication of untreated strep throat infections. It is usually accompanied by mitral and aortic valvular disease
Valvular heart disease
Valvular heart disease is any disease process involving one or more of the valves of the heart . Valve problems may be congenital or acquired...
. Another condition directly harming the valve is tricuspid endocarditis
Endocarditis
Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves . Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or even on intracardiac devices...
.
It may be found in those with a type of congenital heart disease called Ebstein's anomaly
Ebstein's anomaly
Ebstein anomaly is a congenital heart defect in which the opening of the tricuspid valve is displaced towards the apex of the right ventricle of the heart.-Presentation:...
.
Other infrequent causes of tricuspid regurgitation include:
- Carcinoid tumors, which release a hormone which damages the valve
- Connective tissue diseases such as Marfan syndromeMarfan syndromeMarfan syndrome is a genetic disorder of the connective tissue. People with Marfan's tend to be unusually tall, with long limbs and long, thin fingers....
- Systemic lupus erythematosusSystemic lupus erythematosusSystemic lupus erythematosus , often abbreviated to SLE or lupus, is a systemic autoimmune disease that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage...
- Myxomatous degenerationMyxomatous degenerationMyxomatous degeneration refers to a pathological weakening of connective tissue. The term is most often used in the context of mitral valve prolapse, which is known more technically as "primary form of myxomatous degeneration of the mitral valve."...
- Injury
- Rheumatoid arthritisRheumatoid arthritisRheumatoid arthritis is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks synovial joints. The process produces an inflammatory response of the synovium secondary to hyperplasia of synovial cells, excess synovial fluid, and the development...
- Radiation therapyRadiation therapyRadiation therapy , radiation oncology, or radiotherapy , sometimes abbreviated to XRT or DXT, is the medical use of ionizing radiation, generally as part of cancer treatment to control malignant cells.Radiation therapy is commonly applied to the cancerous tumor because of its ability to control...
Another important risk factor for tricuspid regurgitation is use of the diet medications called "Fen-Phen
Fen-phen
The drug combination fenfluramine/phentermine, usually called fen-phen, is an anti-obesity treatment that utilizes two anorectics. Fenfluramine, its S-enantiomer dexfenfluramine, and a few other serotonin agonists were shown to cause potentially fatal pulmonary hypertension and heart valve...
" (phentermine and fenfluramine) or dexfenfluramine
Symptoms and Signs
SymptomsTricuspid insufficiency may be asymptomatic, especially if right ventricular function is well preserved. Symptoms are generally those of right-sided heart failure, such as ascites
Ascites
Ascites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
, hepatomegaly
Hepatomegaly
Hepatomegaly is the condition of having an enlarged liver. It is a nonspecific medical sign having many causes, which can broadly be broken down into infection, direct toxicity, hepatic tumours, or metabolic disorder. Often, hepatomegaly will present as an abdominal mass...
, edema
Edema
Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...
and jugular venous distension Vague upper abdominal discomfort (from a congested liver), and fatigue (due to diminished cardiac output
Cardiac output
Cardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...
) can all be present to some degree.
Signs
Medical sign
A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....
On examination, the jugular venous pressure
Jugular venous pressure
The jugular venous pressure is the indirectly observed pressure over the venous system...
is usually elevated, and 'CV' waves can be seen. It features prominent V waves and rapid y descents in jugular venous pressure
Jugular venous pressure
The jugular venous pressure is the indirectly observed pressure over the venous system...
The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency). Peripheral edema is often found. In severe cases, there may be ascites
Ascites
Ascites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
and even cirrhosis
Cirrhosis
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules , leading to loss of liver function...
(so-called 'cardiac cirrhosis').
Triscuspid insufficiency may lead to the presence of a pansystolic heart murmur
Heart murmur
Murmurs are extra heart sounds that are produced as a result of turbulent blood flow that is sufficient to produce audible noise. Most murmurs can only be heard with the assistance of a stethoscope ....
. Such a murmur is usually of low frequency and best heard low on the lower left sternal border. It tends to increase with inspiration, and decrease with expiration and Valsalva maneuver
Valsalva maneuver
The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut...
. However, the murmur may be inaudible reflecting the relatively low pressures in the right side of the heart. A third heart sound
Third heart sound
The third heart sound or S3 is a rare extra heart sound that occurs soon after the normal two "lub-dub" heart sounds .-Physiology:It occurs at the beginning of diastole approximately 0.12 to 0.18 seconds after S2...
may also be present, also heard best with inspiration at the left lower sternal border. Parasternal heave
Parasternal heave
A parasternal heave is a praecordial impulse that may be palpable in patients with cardiac or respiratory disease. A parasternal impulse may be felt when the heel of the hand is rested just to the left of the sternum with the fingers lifted slightly off the chest. Normally no impulse or a slight...
may be felt along the left lower sternal border as well.
Atrial fibrillation
Atrial fibrillation
Atrial fibrillation is the most common cardiac arrhythmia . It is a common cause of irregular heart beat, identified clinically by taking a pulse. Chaotic electrical activity in the two upper chambers of the heart result in the muscle fibrillating , instead of achieving coordinated contraction...
is usually present.
Diagnosis
Diagnosis is usually made by echocardiography identifying tricuspid prolapse or flail The finding of a pulsatile liver and/or the presence of prominent CV waves in the jugular pulse is also essentially diagnostic.Electrocardiography assists in the diagnosis, indicating enlargement of right ventricle and atrium.
Therapy
The main therapy is treatment of underlying cause. In most cases, surgery is not indicated since the root problem lies with a dilated or damaged right ventricleRight ventricle
The right ventricle is one of four chambers in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk....
. Medical therapy with diuretics is the mainstay of treatment. Unfortunately, this can lead to volume depletion and decreased cardiac output
Cardiac output
Cardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...
. Indeed, one must often accept a certain degree of symptomatic tricuspid insufficiency in order to prevent a decrease in cardiac output. Treatment with medicines to reduce cardiac afterload
Afterload
Afterload is the tension or stress developed in the wall of the left ventricle during ejection. Following Laplace's law, the tension upon the muscle fibers in the heart wall is the product of the pressure within the ventricle, multiplied by the volume within the ventricle, divided by the wall...
may also be of benefit but a similar risk of depressed cardiac output applies.
Where surgery has to be performed, the following alternatives are available:
-
- Tricuspid valvular repairHeart valve repairHeart valve repair is a surgical technique used to fix defects in heart valves in valvular heart diseases, and provides an alternative to valve replacement. Without further specification, it refers to native heart valve repair, rather than repair of an artificial heart...
- Valvuloplasty
- Valve replacementValve replacementValve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis . It is an alternative to valve repair.There are four procedures:...
(rarely performed)
- Tricuspid valvular repair
External links
- http://www.merck.com/mmpe/sec07/ch076/ch076i.html
- http://emedicine.medscape.com/article/158484-overview
- http://www.nlm.nih.gov/medlineplus/ency/article/000169.htm