Tricuspid regurgitation: causes, symptoms, diagnosis, treatment

Tricuspid regurgitation is a failure of the tricuspid valve, leading to a flow of blood from the right ventricle to the right atrium during systole. The most common cause is dilatation of the right ventricle. Symptoms of tricuspid regurgitation are usually absent, but severe tricuspid regurgitation can cause pulsation of the veins of the neck, hysterostolic noise and right ventricular heart failure or atrial fibrillation. Diagnosis is established by physical examination and echocardiography. Tricuspid regurgitation is usually a benign condition that does not require treatment, but some patients need anuloplasty, valve plastic, its prosthesis or excision.

Causes of tricuspid regurgitation

Most often, tricuspid regurgitation is caused by the expansion of the right ventricle (RV) with a malfunction in the normal valve. Such situations occur with pulmonary arterial hypertension caused by right ventricular dysfunction, heart failure (CH), and obstruction of the outgoing tract of the pulmonary artery. Rarely tricuspid regurgitation develops as a result of infective endocarditis in drug addicts who practice intravenous injections; carcinoid syndrome, rheumatic fever, idiopathic myxomatous degeneration, ischemic dysfunction of papillary muscle, birth defects (eg, split tricuspid valve, endocardial defects), Epstein's defect (downward displacement of the modified tricuspid valve flaps in the right ventricle), Marfan syndrome and certain medications (e.g., ergotamine, fenfluramine, phentermine).

Prolonged severe tricuspid regurgitation can lead to a conditioned dysfunction of the right ventricle, heart failure and atrial fibrillation (MA).

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Symptoms of tricuspid regurgitation

Tricuspid regurgitation usually does not cause any symptoms, but some patients note neck veins pulsation due to increased pressure in the jugular veins. Acute or severe tricuspid regurgitation can provoke heart failure due to RV dysfunction. Possible manifestations of fibrillated arrhythmia or atrial flutter.

The only visible sign of moderate or severe tricuspid regurgitation is the swelling of the jugular veins, with a markedly smoothed cv (or s) wave and a steep decrease in y. In severe tricuspid regurgitation, palpitation of the right jugular veins can be palpated, as well as systolic hepatic pulsation and contractions of the right ventricle at the left lower edge of the sternum. With auscultation, I heart tone (S1 may be normal or weak if there is tricuspid regurgitation noise.

The second heart tone (S2) can be split (with a loud pulmonary component of P with pulmonary arterial hypertension) or single due to rapid closure of the pulmonary artery valve, coinciding with P and aortic component (A).

The III cardiac tone of the right ventricle (S3), IV heart tone (S4), or both may be audible in heart failure caused by right ventricular dysfunction or hypertrophy of the prostate. These tones can be distinguished from the left ventricular heart tones, since they are located in the fourth intercostal space to the left of the sternum and intensified by inhalation.

The noise of tricuspid regurgitation is a holosystolic murmur. It is heard best to the right or to the left of the sternum at the level of its middle or in the epigastric region through a stethoscope with a diaphragm, when the patient sits straight or stands. Noise can be high-frequency if tricuspid regurgitation is functional or caused by pulmonary hypertension or mid-frequency if tricuspid regurgitation is severe and has other causes. The noise changes with breathing, becoming louder on inspiration (Carvalho's symptom), and with other techniques that increase the venous influx (lifting of the foot, pressing on the liver, after the ventricular extrasystole). Noise usually does not radiate, but is sometimes heard over the liver.

Diagnosis of tricuspid regurgitation

Light tricuspid regurgitation is most often detected with echocardiography performed for other reasons. Presumptive diagnosis of more severe or severe tricuspid regurgitation is raised during the collection of anamnesis, physical examination and confirmed by Doppler echocardiography. ECG and chest radiography are often performed. ECG data is usually normal, but in some cases high pointed pins P, caused by right atrial dilatation, high R and QR teeth in V1 lead characterizing right ventricular hypertrophy, or MA are revealed. Chest X-ray is usually normal, but in some cases, with right ventricular hypertrophy or heart failure due to right ventricular dysfunction, you can see an enlarged upper vena cava, an enlarged right atrium or a right ventricle outline (behind the upper part of the sternum in the lateral projection) or detect a pleural effusion.

Cardiac catheterization is rarely prescribed. If it is still performed (for example, to assess the anatomy of the coronary vessels), the findings include a pronounced atrial systolic wave v during ventricular systole and normal or increased atrial systolic pressure.

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Prognosis and treatment of tricuspid regurgitation

Since isolated expressed tricuspid regurgitation develops in a small number of patients, there is little reliable data on the prognosis.

Tricuspid regurgitation is usually well tolerated and does not require treatment by itself. The elimination of the causes of tricuspid regurgitation (eg, heart failure, endocarditis) is shown. Surgical treatment is prescribed for patients with moderate or severe tricuspid regurgitation and lesions of the left-sided valves (for example, mitral stenosis) leading to the development of pulmonary arterial hypertension and high pressure in the right ventricle (mitral valve plastic is needed). In such patients, surgical intervention can prevent death due to poor cardiac function. Surgical treatment can also be prescribed for patients with severe mitral regurgitation, accompanied by clinical symptoms, when the pressure in the left atrium is <60 mm Hg. Art.

Surgical methods include anuloplasty, valve plastic and prosthetics. Anuloplasty, in which the tricuspid valve ring is sutured to the prosthetic ring or the circumference of the ring is performed, is prescribed in cases where tricuspid regurgitation develops as a result of dilatation of the ring. Plastic or prosthetic valve are indicated when tricuspid regurgitation develops due to a primary lesion of the valve or when anuloplasty is technically impossible. Prosthesis of tricuspid valve is performed when tricuspid regurgitation is a consequence of carcinoid syndrome or Epstein's defect. Use a pork valve to reduce the risk of thromboembolism associated with low flow and pressure in the right heart; unlike the left divisions in the right, the pork valves function for more than 10 years.

If the tricuspid valve is damaged due to endocarditis, if the latter can not be cured with antibiotics, the valve is completely excised and the implant is not implanted for 6-9 months; patients tolerate such interference well.