What You Should Know About Tricuspid Regurgitation

When is it a problem and when is it not?

Tricuspid Valve
Tricuspid Valve. ROGER HARRIS/Getty Images

Tricuspid regurgitation—a “leaky” tricuspid valve—is a fairly common heart valve disorder. Many people with tricuspid regurgitation are very surprised to learn that they have a heart valve issue because they feel fine. Their doctors are often as surprised as they are and may not know what to make of it.

If you are told you have tricuspid regurgitation, what does that mean? How should you and your doctor think about this problem and what should you do next?

 

The tricuspid valve separates the right atrium from the right ventricle. Like all heart valves, the purpose of the tricuspid valve is to make sure blood flows through the heart in the right direction. So, when the right atrium contracts, the tricuspid valve is forced open, to allow blood to flow into the right ventricle. A split second later, when the right ventricle contracts to eject its blood into the pulmonary artery, the tricuspid valve closes to keep blood from flowing backwards into the right atrium.

With tricuspid regurgitation, the tricuspid valve fails to close completely. This allows at least some blood to flow backwards—that is, to regurgitate—into the right atrium as the right ventricle contracts. 

How Much of a Problem Is Tricuspid Regurgitation?

Merely telling a person that they have tricuspid regurgitation is not very helpful, because the significance of this valve disorder varies between none and severe.

At least some tricuspid regurgitation is seen in up to 70 percent of normal adults who have echocardiograms. As the right ventricle contracts, it takes a moment or two for a normal tricuspid valve to close completely, and during that moment a small whiff of blood leaks back into the right atrium.

With today’s technology, the echocardiogram is often sensitive enough to detect that “normal” whiff of blood—and these individuals, whose valves are essentially normal, are often told they have tricuspid regurgitation, and therefore, a heart valve problem.

(As an aside, the same thing happens to some extent with the mitral valve, leading many people to be inappropriately “diagnosed” with mitral valve prolapse or MVP.)

So the first question to ask if you are told you have tricuspid regurgitation is: How severe is it? If the answer is “very mild,” it is likely that you have nothing to worry about. 

However, if the tricuspid regurgitation is judged to be moderate or severe, a significant heart problem is much more likely to be present. In this case, a thorough cardiac evaluation ought to be done to determine the cause and extent of the tricuspid regurgitation.

What Are the Causes?

Damage to the tricuspid valve itself can cause tricuspid regurgitation. Conditions that can damage the tricuspid valve include: 

  • Congenital heart disease

However, the more common cause of tricuspid regurgitation, by far, is a “functional’ disturbance of the tricuspid valve. With functional tricuspid regurgitation, the valve itself is essentially normal. The leakage across the valve occurs because a heart disorder of some kind distorts the heart—for instance, by dilating the right atrium or the right ventricle in a way that prevents the tricuspid valve from closing completely.

Heart problems that commonly cause functional tricuspid regurgitation include:

Most people with significant tricuspid regurgitation have functional tricuspid regurgitation, and a full evaluation will reveal one of these underlying disorders.

What Are the Symptoms?

The large majority of people with tricuspid regurgitation have no symptoms that can be attributed to the tricuspid regurgitation itself. Any symptoms, if present, are usually caused by the underlying condition that is producing a functional valve problem.

However, if the tricuspid regurgitation is severe, it may produce a feeling of an unusual pulsation in the neck. And sometimes very severe tricuspid regurgitation can cause abdominal pain and swelling. But even severe tricuspid regurgitation often produces no symptoms at all.

What Happens After a Diagnosis?

The two key questions after tricuspid regurgitation is diagnosed ought to be:

  1. What is the underlying cause? 
  2. How severe is it?

Both of these questions are important in deciding how—and even whether—to treat the problem.

In most cases, these two questions are answered quite readily when the doctor performs a careful medical history and physical examination and obtains a high-quality echocardiogram. At that point, a management plan can be developed.

How Should Tricuspid Regurgitation Be Managed?

The most important step in managing tricuspid regurgitation is to identify and treat the underlying cause. This is especially important with functional tricuspid regurgitation, where the tricuspid valve itself is fundamentally normal.

Functional tricuspid regurgitation is most often caused by pulmonary artery hypertension. Treating pulmonary hypertension can substantially improve the tricuspid regurgitation. So, reversible causes of pulmonary hypertension—especially heart failure, mitral valve disease, or pulmonary embolus—ought to be aggressively treated.

If the tricuspid regurgitation is not functional—that is, it is caused by an intrinsic problem with the tricuspid valve itself—management usually depends on the severity of the regurgitation and any associated symptoms.

People who have only very mild tricuspid regurgitation without any other cardiac problems probably have fundamentally normal tricuspid valves, and, except for periodic follow-up examinations, need no “management” at all. 

Even if intrinsic tricuspid regurgitation is moderate or severe, as long as there are no symptoms and the echocardiogram shows normal cardiac function and normal heart pressures, there should be no limitation placed on physical activity. The only real “management” is periodic re-evaluations with a cardiologist.

What About Tricuspid Valve Surgery?

There are a few situations in which valve surgery ought to be considered in people who have tricuspid regurgitation.

Surgery should become an option if the tricuspid regurgitation itself is judged to be causing significant symptoms. 

Tricuspid valve surgery is also recommended for people who have severe tricuspid regurgitation and are having surgery to repair or replace a diseased mitral valve. That is, both valves are dealt with during one operation. This, by far, is the most common reason for performing tricuspid valve surgery.

In general, whenever it is feasible, repair of the tricuspid valve is preferred over valve replacement. 

Summary

If you are told you have tricuspid regurgitation, the key is for your doctor to expeditiously determine the underlying cause and the severity of the problem. Fortunately, this is usually not a difficult or time-consuming process.

The majority of people diagnosed with tricuspid regurgitation will turn out to have a mild form of the disorder or no disorder at all. Of those whose tricuspid regurgitation turns out to be a significant problem, most will have a functional valve problem caused by another cardiac disease—and their treatment will require aggressively managing the underlying heart problem. Surgery for tricuspid regurgitation is not commonly needed.

Sources:

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.

Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline 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. J Am Coll Cardiol 2014; 63:e57.

Kara I, Koksal C, Erkin A, et al. Outcomes of Mild to Moderate Functional Tricuspid Regurgitation in Patients Undergoing Mitral Valve Operations: A Meta-Analysis of 2,488 Patients. Ann Thorac Surg 2015; 100:2398.

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