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Tricuspid regurgitation, or tricuspid valve regurgitation, is a medical condition in which the heart’s tricuspid valve fails to close properly. The tricuspid valve connects the two chambers of the right side of the heart, the right atrium and right ventricle.
Normally, as the heart beats, blood flows from the right atrium into the right ventricle. When the tricuspid valve is damaged and cannot close, however, blood from the ventricle backs up, or regurgitates, into the atrium with every heartbeat. As a result, the heart pumps less blood into the lungs to receive oxygen, and blood volume and pressure increase in the right atrium. Ultimately, the heart has to work harder and encounters more stress. Tricuspid regurgitation can cause or worsen ongoing cardiopulmonary (heart and lung) disease and can cause severe symptoms similar to heart failure.
Occasionally tricuspid regurgitation occurs because of a congenital (present at birth) defect or an infection in the tricuspid valve, but it more commonly results from other heart conditions. These include other valve disorders and left-sided heart diseases, as well as lung disorders like chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH). PH, an umbrella term describing high blood pressure in the arteries of the lungs, is a major risk factor for developing tricuspid regurgitation.
In some types of pulmonary hypertension, such as pulmonary arterial hypertension (PAH), the right heart has to work hard to pump blood into the narrowed pulmonary arteries, resulting in hypertrophy (enlargement) of the right ventricle. Over time, this enlargement of the heart muscle, called cardiomyopathy, can distort the tricuspid valve and lead to regurgitation.
PH and tricuspid regurgitation have a cyclical relationship. When the right ventricle becomes enlarged, it impairs the function of the tricuspid valve. When the tricuspid valve is impaired, the heart has to work harder, further worsening PH. Severe tricuspid regurgitation is linked with the progression of pulmonary hypertension and can contribute to increased death rates in people with both conditions.
Pulmonary hypertension can often lead to tricuspid regurgitation. As such, there can be a high degree of overlap in risk factors between the two conditions, depending on the classification of tricuspid regurgitation.
Tricuspid regurgitation is classified as either primary or secondary based on its underlying cause. Primary, or organic, tricuspid regurgitation occurs when there is direct damage to parts of the valve. Congenital conditions, infections, and trauma caused by implantation of a pacemaker are all causes of the primary type.
Secondary, or functional, tricuspid regurgitation occurs when there is stretching or dilatation (expansion) of the part of the valve called the annulus, which is the ring of tissue where the valve’s leaflets sit. The leaflets are the parts that close together, and when their base becomes distended (swollen), they no longer close properly.
Functional tricuspid regurgitation can develop as a result of PH, as well as from left-sided heart disease, and thus the conditions share many risk factors. Generally, the severity of secondary tricuspid regurgitation is determined by the severity of the underlying PH or left-sided heart disease.
Heart conditions that alter blood flow between the heart and lungs and increase pulmonary arterial pressure are potential causes of pulmonary hypertension (and therefore tricuspid regurgitation). Mitral valve diseases —including mitral regurgitation, in which the valve between the left atrium and left ventricle becomes leaky, and mitral valve stenosis, when the valve narrows — are one such risk factor.
Much like tricuspid regurgitation, mitral valve disease increases the workload of the heart. Mitral valve disease can lead to PH that affects the right heart. In a study of 80,000 people undergoing mitral valve surgery, about 17 percent had moderate tricuspid regurgitation and 8.5 percent had severe tricuspid regurgitation.
Many other chronic health conditions are risk factors for PH, including:
People with a family history of PH and those living at high altitudes are also at greater risk of developing PH. Pulmonary hypertension has a higher prevalence in women, who are 2.5 times more likely than men to develop PAH, according to the Pulmonary Hypertension Association of Canada. Additionally, the cause of many cases of PAH is unknown.
Many people with mild tricuspid regurgitation have no symptoms. If their condition becomes severe, they may experience signs and symptoms, which include:
Because tricuspid regurgitation is often the result of another heart condition, such as PH, additional symptoms can arise from that underlying condition. Common symptoms associated with PH overlap with tricuspid regurgitation, such as shortness of breath, fatigue, and weakness.
The symptoms of tricuspid regurgitation are similar to those of PH and other cardiopulmonary diseases, and tricuspid regurgitation can worsen related heart and lung conditions. These factors make it important to identify tricuspid regurgitation when other conditions, such as PH, are suspected.
Because symptoms are often not present in mild or even moderate cases, identifying tricuspid regurgitation early is challenging but important. A number of diagnostic tests can help confirm and monitor this condition.
A doctor may suspect tricuspid regurgitation based on a person’s history and symptoms, or they may notice a characteristic heart murmur during a physical exam.
The primary test to examine the heart for tricuspid regurgitation is a Doppler echocardiogram. This test uses sonography, or sound waves, to create a picture of the heart as it beats. These sound waves allow the doctor to visualize how the heart beats and examine the hemodynamics, or how the blood moves through the heart. The most common form of echocardiographic assessment is transthoracic echocardiography, in which the measurements are taken by placing an ultrasound probe on the person’s chest.
A doctor might instead use transesophageal echocardiography, which is more invasive. During a transesophageal echocardiogram, a thin tube is placed down into the esophagus through the mouth. This method can help the doctor more directly see the tricuspid valve function, without the ribs or lungs obscuring the view.
During the echocardiogram, a doctor will look for signs of ventricular dysfunction by using measures like tricuspid annular plane systolic excursion (TAPSE). TAPSE can be used to examine right ventricle function and detect causes of tricuspid regurgitation, like right ventricle dilatation. Additionally, they will examine the tricuspid valve’s shape and movement, as well as the way blood flows through the valve as the heart beats.
A doctor may also recommend an electrocardiogram (ECG or EKG), a noninvasive procedure that measures the electrical activity of the heart. An ECG can help detect heart strain as well as abnormal heart rhythms.
Echocardiography and ECG are also used in diagnosis of pulmonary hypertension. If a doctor suspects PH, they may perform an additional test called right heart catheterization. This test can show doctors where blood pressure is high, which can assist in making a specific diagnosis and treatment plan.
Right heart catheterization is an invasive procedure, with a thin tube, or catheter, guided through different chambers of the heart and pulmonary arteries. One hallmark of PH is a pulmonary artery pressure greater than 20 millimeters of mercury (mm Hg) and increased right atrial pressure, which is most accurately measured using right heart catheterization.
Although this test is frequently called the gold standard for measuring PH, it is not often recommended for diagnosing tricuspid regurgitation. In some cases, however, it may be used to determine the cause of the tricuspid malfunction.
The main goal in managing tricuspid regurgitation is to treat any underlying conditions. When PH and tricuspid regurgitation occur together, this means treating pulmonary hypertension with medications that specifically lower blood pressure in the lungs. In cases of left-sided heart disease, treatments like beta-blockers and diuretics may be used to reduce strain on the heart and lower the body’s blood pressure. Medications may also be used to treat the complications of tricuspid regurgitation, such as abnormal heart rhythms, heart failure, and blood clots.
If a person’s tricuspid regurgitation is severe or contributing to heart failure, a doctor may recommend surgical intervention, which may involve valve repair or replacement. Tricuspid valve surgery is sometimes performed during surgery for related heart conditions, such as mitral valve surgery.
Management of tricuspid regurgitation and PH is difficult — both diseases are complex. Regular follow-up with a cardiac care team is important because the presence of both conditions can carry a negative prognosis (outlook) and an increased risk of death when not treated properly. The good news is that tricuspid regurgitation is gaining recognition, and researchers are urging health care providers to look for risk factors during routine work-ups for other heart conditions.
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