Etiology, clinical features, and evaluation of tricuspid regurgitation
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
Tricuspid regurgitation (TR) is a relatively common abnormality. Since this lesion is frequently asymptomatic and may not be detected on physical examination, it is often diagnosed solely by echocardiography. This topic will review the etiology, pathophysiology, and clinical features associated with regurgitation of the tricuspid valve.
Management and prognosis of tricuspid regurgitation and Ebstein's anomaly of the tricuspid valve are discussed separately. (See "Management and prognosis of tricuspid regurgitation" and "Clinical manifestations and diagnosis of Ebstein anomaly".)
A small degree of tricuspid regurgitation (TR) is present in approximately 70 percent of normal adults. On echocardiography, this "normal" or physiological degree of regurgitation is localized to a small region adjacent to valve closure, often does not extend throughout systole, and has a low signal strength .
Abnormal degrees of TR in adults are largely functional (ie, related to tricuspid annular dilation and/or leaflet tethering in the setting of right ventricular pressure and/or volume overload) and much less often due to primary disorders of the valve apparatus [2-4]. The frequency of TR as well as valvular pathology was evaluated in a study of 5223 adults (predominantly male with a mean age of 67) who underwent echocardiography at three Veterans Affairs medical centers . Moderate to severe TR was present in 819 (15.7 percent), but only 8 percent had primary tricuspid valve pathology.
Functional TR — TR in adults is most commonly functional, defined as regurgitation with apparently anatomically normal leaflets and chords. The cause of functional TR most likely is dilatation of the right atrium and right ventricle with dilation of the tricuspid annulus  and tethering of the tricuspid valve leaflets , although the mechanism of valve dysfunction has not been fully defined. Right ventricular dilatation, tricuspid annular dilatation, and tricuspid leaflet tethering may result from any condition that directly involves the right ventricle or causes elevation in right ventricular systolic pressure often with pulmonary hypertension.
- Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
- Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on long-term survival. J Am Coll Cardiol 2004; 43:405.
- Mutlak D, Lessick J, Reisner SA, et al. Echocardiography-based spectrum of severe tricuspid regurgitation: the frequency of apparently idiopathic tricuspid regurgitation. J Am Soc Echocardiogr 2007; 20:405.
- Nishimura R, Warnes CA. Response: Communication in education. A core competency for the cardiologist. J Am Coll Cardiol 2015; 65:1374.
- Sagie A, Schwammenthal E, Padial LR, et al. Determinants of functional tricuspid regurgitation in incomplete tricuspid valve closure: Doppler color flow study of 109 patients. J Am Coll Cardiol 1994; 24:446.
- Fukuda S, Gillinov AM, Song JM, et al. Echocardiographic insights into atrial and ventricular mechanisms of functional tricuspid regurgitation. Am Heart J 2006; 152:1208.
- Waller BF, Howard J, Fess S. Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part III. Clin Cardiol 1995; 18:225.
- Yamasaki N, Kondo F, Kubo T, et al. Severe tricuspid regurgitation in the aged: atrial remodeling associated with long-standing atrial fibrillation. J Cardiol 2006; 48:315.
- Mutlak D, Aronson D, Lessick J, et al. Functional tricuspid regurgitation in patients with pulmonary hypertension: is pulmonary artery pressure the only determinant of regurgitation severity? Chest 2009; 135:115.
- Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
- Pritchett AM, Morrison JF, Edwards WD, et al. Valvular heart disease in patients taking pergolide. Mayo Clin Proc 2002; 77:1280.
- Baseman DG, O'Suilleabhain PE, Reimold SC, et al. Pergolide use in Parkinson disease is associated with cardiac valve regurgitation. Neurology 2004; 63:301.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Maeder MT, Holst DP, Kaye DM. Tricuspid regurgitation contributes to renal dysfunction in patients with heart failure. J Card Fail 2008; 14:824.
- Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 2009; 53:589.
- Functional TR
- Valvular abnormalities
- PHYSICAL EXAMINATION
- Jugular veins
- Cardiac auscultation
- - Murmur
- - Maneuvers
- - Heart sounds
- Chest radiograph
- Cardiovascular magnetic resonance
- Cardiac catheterization and angiography
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS