Tricuspid insufficiency (tricuspid valve closure) is rarely caused by involvement of the valve leaflets themselves, but more often by pulmonary hypertension and tricuspid dilatation. It is commonly associated with significant mitral valve disease and chronic pulmonary heart disease.
Diagnosis
The diagnosis is usually easy to make on the basis of a typical murmur, right ventricular right atrial enlargement, and signs and symptoms of circulatory stasis. Echocardiographic acoustic imaging and Doppler ultrasonography can confirm the diagnosis and help make an etiologic diagnosis.
Treatment
Simple tricuspid valve insufficiency without pulmonary hypertension, if secondary to infective endocarditis or trauma, generally does not require surgical treatment. Active treatment of other causes of heart failure may improve the severity of functional tricuspid regurgitation. Mitral valve lesions with pulmonary hypertension and right ventricular enlargement, correct the mitral valve abnormalities, reduce pulmonary artery pressure, tricuspid insufficiency can be gradually reduced or disappear without special treatment; serious organic tricuspid valve lesions, especially rheumatic without severe pulmonary hypertension, can be carried out annuloplasty or artificial heart valve replacement.
Aetiology
Tricuspid valve insufficiency is caused by pulmonary hypertension and tricuspid valve dilatation. Common in significant mitral valve disease and chronic pulmonary heart disease, involving the right ventricle of the lower wall of myocardial infarction, rheumatic or congenital heart disease pulmonary hypertension caused by advanced heart failure, ischemic heart disease, cardiomyopathy; rare, such as rheumatic tricuspid valvulitis valve shortening deformity, often combined with tricuspid stenosis; congenital Ebstein's anomaly; infective endocarditis due to the valve damage; tricuspid valve prolapse, this kind of Tricuspid valve prolapse, which is often associated with mitral valve prolapse, is common in Marfan syndrome; it can also be seen in right atrial mucinous tumor, right ventricular myocardial infarction, and after chest trauma.
Acquired simple tricuspid insufficiency can occur in carcinoid syndrome because carcinoid plaque often deposits on the ventricular surface of the tricuspid valve and adheres the valve cusp to the wall of the right ventricle, causing tricuspid insufficiency, which is often accompanied by pulmonary valve disease. Tricuspid insufficiency is often accompanied by marked enlargement of the right heart.
Clinical manifestations
Tricuspid insufficiency causes pathophysiologic changes on the right side of the heart similar to the effects of mitral insufficiency on the left side of the heart, but the compensatory period is longer; the condition, if progressing gradually, can ultimately lead to hypertrophy of the right ventricle and the right atrium, and the right ventricle fails. The disease progresses more rapidly in those caused by significant pulmonary hypertension.
(I) Symptoms When tricuspid valve insufficiency is combined with pulmonary hypertension, the symptoms of reduced cardiac output and circulatory stasis may appear. In patients with tricuspid valve insufficiency combined with mitral valve disease, the symptoms of pulmonary stasis may be reduced by the progression of tricuspid valve insufficiency, but fatigue and other symptoms of decreased cardiac output may be more severe.
(2) Signs and symptoms The main sign is the full systolic murmur at the left lower edge of the sternum, which can be enhanced by inspiration and compression of the liver; however, the murmur is difficult to be enhanced if the right ventricle of the failing heart is unable to increase the volume of the heart beat. The third heart sound and low-pitched mid-diastolic murmur in the tricuspid valve area are present only when the flow is high. The jugular venous pulsatility v-wave (also known as the reflux wave, caused by the return of blood to the large right atrial vein during right ventricular systole) is enlarged; liver pulsations may be detected. In valvular prolapse, a non-jetty click can be heard in the tricuspid region. The signs of bruising are the same as in right heart failure.
Auxiliary examination
(I) X-ray examination, the right ventricle and right atrium can be seen enlarged. In the case of elevated right atrial pressure, dilatation of the odd vein and pleural effusion can be seen; in the case of ascites, the diaphragm is elevated. Right atrial systolic pulsation can be seen on fluoroscopy.
(2) Electrocardiography may show right ventricular hypertrophy and strain, right atrial hypertrophy; and often right bundle branch conduction block.
(3) Echocardiography shows enlargement of the right ventricle and right atrium, widening of the upper and lower vena cava and pulsation; and a flail-like tricuspid valve. Two-dimensional echocardiographic acoustic contrast confirms regurgitation, and Doppler ultrasonography determines the degree of regurgitation and pulmonary hypertension.
Differential diagnosis
It should be differentiated from mitral valve closure insufficiency with low ventricular septal defect.
Mitral valve insufficiency: typical blowing systolic murmur in the apical region with left atrial and left ventricular enlargement.
Tricuspid valve insufficiency: a limited wind-blowing systolic murmur is heard at the lower left sternal border, which is enhanced by increased regurgitant blood flow during inspiration and diminished during expiration. In pulmonary hypertension, the second heart sound of the pulmonary valve is hyperactive, and the jugular vein v-wave is enlarged. The liver may be pulsatile and enlarged. Right ventricular hypertrophy is seen on ECG and X-ray. Echocardiography can clarify the diagnosis.