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A. Associationsnavigator

  1. Endocarditis [1]
    1. Tricuspid valve vegetations found in >95% of endocarditis associated with drug abuse
    2. Staphylococcus aureus infection is most common
    3. Regurgitation is most common lesion
    4. Reduced cardiac output and hypotension can occur
  2. Gastrointestinal and Liver Carcinoids [2]
    1. Tricuspid disease, usually manifesting intially with murmur ~30%
    2. Mitral (or aortic) valve disease suggests pulmonary carcinoid ~10%
    3. Due primarily to production of serotonin by carcinoid
    4. Serotonin induces valvular degeneration
    5. Progression to heart failure can occur
  3. Serotonergic Drug Use
    1. Anorexic Agents [3,4,5,6]
    2. Ergot Alkaloids [7]
    3. Stenotic or regurgitant lesions can occur
  4. Congenital heart disease - especially Epstein's Anomaly

B. Pathophysiological Changes navigator

  1. Tricuspid Regurgitation
    1. Inadequate perfusion of pulmonary arteries (PA)
    2. Enlargement of right ventricle (RV) to compensate for low volume forward (PA) output
    3. Overdistension of right atrium (RA, low pressure conduit)
    4. Increased risk for development of atrial fibrillation (due mainly to RA distension)
    5. Left atrial filling is compromised
    6. Venous system is congested
  2. Tricuspid Stenosis
    1. Underfilling of RV
    2. Enlargement with thickening of RA (increased RA pressure needed to bypass stenosis)
    3. Increased pressure in venous return system (peripheral edema, "V" waves)

C. Symptoms of Tricuspid Valve Diseasenavigator

  1. Reduced cardiac output occurs due to underfill of lungs and left ventricle
  2. Marked jugular venous distension (JVD)
  3. Increased venous pressures
    1. Peripheral dependent pitting edema
    2. Lower extremity venous stasis changes
    3. Portal pressures can increase leading to transudative ascites
  4. Atrial fibriallation increased risk with both tricuspid regurgitation and stenosis
  5. Symptoms of Heart failure
    1. High output cardiac failure
    2. Shortness of breath
    3. Dyspnea on exertion
    4. Problems worsen with increasing heart rate

D. Diagnosis of Tricuspid Valve Diseasenavigator

  1. Tricuspid sounds: center lower region of chest (between thoracic ribs 3/4)
  2. Mid aortic outflow tract - lower left sternal border
  3. Regurgitation murmer increases on inhalation
  4. ECG for signs of atrial enlargement, atrial fibrillation
  5. Echocardiogram required for accurate diagnosis

E. Treatmentnavigator

  1. Caution with diuresis because left ventricle preload is highly reduced
  2. Maintain normal heart rate to permit adequate ventricular filling
  3. Moderate to severe tricuspid regurgitation must be treated with valve replacement

References navigator

  1. Siddiq S, Missri J, Silverman DI. 1996. Arch Intern Med. 156(21):2454 abstract
  2. Kulke MH and Mayer RJ. 1999. NEJM. 340(11):858 abstract
  3. Connolly HM, Crary JL, McGoon MD, et al. 1997. NEJM. 337(9):581 abstract
  4. Khan MA, Herzog CA, St Peter JV, et al. 1998. NEJM. 339(11):731
  5. Jick H, Vasilakis C, Weinrauch LA, et al. 1998. NEJM. 339(11):719 abstract
  6. Weissman NJ, Tighe JF Jr, Gottdiener JS, Gwynne JT. 1998. NEJM. 339(11):725 abstract
  7. Redfield MM, Nicholson WJ, Edwards WD, Tajik AJ. 1992. Ann Intern Med. 117(1):50 abstract