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Tricuspid regurgitation: causes, symptoms, diagnosis, treatment
Last reviewed: 05.07.2025
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Tricuspid regurgitation is insufficiency of the tricuspid valve, resulting in blood flow from the right ventricle into the right atrium during systole. The most common cause is dilation of the right ventricle. Symptoms of tricuspid regurgitation are usually absent, but severe tricuspid regurgitation may cause neck venous pulsations, a holosystolic murmur, and right ventricular heart failure or atrial fibrillation. Diagnosis is by physical examination and echocardiography. Tricuspid regurgitation is usually benign and requires no treatment, but some patients require anuloplasty, valve repair, valve replacement, or excision.
Causes of tricuspid regurgitation
Most commonly, tricuspid regurgitation is caused by right ventricular (RV) dilation with dysfunction of the normal valve. Such situations occur in pulmonary arterial hypertension due to right ventricular dysfunction, heart failure (HF), and pulmonary artery outflow tract obstruction. Less commonly, tricuspid regurgitation occurs as a result of infective endocarditis in intravenous drug users, carcinoid syndrome, rheumatic fever, idiopathic myxomatous degeneration, ischemic papillary muscle dysfunction, congenital defects (eg, cleft tricuspid valve, endocardial defects), Epstein malformation (downward displacement of abnormal tricuspid valve leaflets into the right ventricle), Marfan syndrome, and the use of certain medications (eg, ergotamine, fenfluramine, phentermine).
Long-term severe tricuspid regurgitation can lead to right ventricular dysfunction, heart failure, and atrial fibrillation (AF).
[ Symptoms of tricuspid regurgitation
Tricuspid regurgitation usually causes no symptoms, but some patients experience neck vein pulsations due to increased jugular venous pressure. Acute or severe tricuspid regurgitation may precipitate heart failure due to RV dysfunction. Atrial fibrillation or atrial flutter may occur.
The only visible sign of moderate to severe tricuspid regurgitation is jugular venous distension, with a markedly flattened cv (or s) wave and a steep decline in y. In severe tricuspid regurgitation, a thrill of the right jugular veins may be palpated, as may a systolic hepatic pulsation and right ventricular contractions at the left lower sternal border. On auscultation, the first heart sound (S1) may be normal or diminished if a tricuspid regurgitation murmur is present.
The second heart sound (S2) may be split (with a loud pulmonary component P in pulmonary arterial hypertension) or single due to rapid closure of the pulmonary valve, coinciding with P and the aortic component (A).
A right ventricular third heart sound (S3), fourth heart sound (S4), or both may be heard in heart failure due to right ventricular dysfunction or RV hypertrophy. These sounds can be distinguished from the left ventricular heart sounds because they are located in the fourth intercostal space to the left of the sternum and increase in intensity with inspiration.
The tricuspid regurgitation murmur is a holosystolic murmur. It is best heard to the right or left of the sternum at the level of its middle or in the epigastric region through a stethoscope with a diaphragm when the patient is sitting upright or standing. The murmur may be high-pitched if tricuspid regurgitation is functional or caused by pulmonary hypertension, or mid-pitched if tricuspid regurgitation is severe and has other causes. The murmur changes with respiration, becoming louder on inspiration (Carvalho's sign), and with other maneuvers that increase venous inflow (leg lift, liver compression, after ventricular extrasystole). The murmur usually does not radiate, but is sometimes heard over the liver.
Diagnosis of tricuspid regurgitation
Mild tricuspid regurgitation is most often detected during echocardiography performed for other reasons. The diagnosis of more significant or severe tricuspid regurgitation is suspected based on the history, physical examination, and Doppler echocardiography. An ECG and chest x-ray are often obtained. The ECG is usually normal but may occasionally show tall, peaked P waves caused by right atrial enlargement or tall R or QR waves in lead V1, indicating right ventricular hypertrophy, or AF. Chest x-ray is usually normal but may occasionally show an enlarged superior vena cava, an enlarged right atrium, an enlarged right ventricular silhouette (behind the upper sternum on the lateral view), or a pleural effusion in cases of right ventricular hypertrophy or heart failure due to right ventricular dysfunction.
Cardiac catheterization is rarely indicated. When it is performed (eg, to evaluate coronary anatomy), findings include a prominent atrial systolic v wave during ventricular systole and normal or elevated atrial systolic pressure.
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Prognosis and treatment of tricuspid regurgitation
Because isolated severe tricuspid regurgitation occurs in a small number of patients, there is little reliable data regarding prognosis.
Tricuspid regurgitation is usually well tolerated and does not require treatment per se. Treatment of the causes of tricuspid regurgitation (eg, heart failure, endocarditis) is indicated. Surgical treatment is indicated in patients with moderate to severe tricuspid regurgitation and left-sided valve lesions (eg, mitral stenosis) leading to pulmonary arterial hypertension and high right ventricular pressure (requiring mitral valve repair). In such patients, surgery may prevent death due to poor cardiac performance. Surgical treatment may also be indicated in patients with severe symptomatic mitral regurgitation, when left atrial pressure is < 60 mmHg.
Surgical options include anuloplasty, valve repair, and valve replacement. Anuloplasty, in which the tricuspid annulus is sutured to a prosthetic ring or the annular circumference is reduced, is indicated when tricuspid regurgitation is due to annular dilation. Valve repair or replacement is indicated when tricuspid regurgitation is due to a primary valvular disorder or when anuloplasty is not technically feasible. Tricuspid valve replacement is performed when tricuspid regurgitation is due to carcinoid syndrome or Epstein's disease. A porcine valve is used to reduce the risk of thromboembolism associated with low flow and pressure in the right heart; unlike the left heart, porcine valves function in the right heart for more than 10 years.
When the tricuspid valve is damaged due to endocarditis, if the latter cannot be cured with antibiotics, the valve is completely excised and a new one is not implanted for 6-9 months; patients tolerate this intervention well.