Mild mitral regurgitation and mild tricuspid regurgitation

Tricuspid regurgitation is leakiness of the tricuspid valve. The tricuspid valve is valve between the upper and lower chambers of the right side of the heart. Everyone has heard of the valve between the upper and lower chambers of the left side of the heart, the mitral valve. The tricuspid valve has been described as the forgotten valve, simply because of how much attention the mitral valve gets! But over recent years the tricuspid valve and tricuspid regurgitation has received much more attention.

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Causes

In general tricuspid regurgitation can be thought of as primary or secondary. In primary tricuspid regurgitation the tricuspid valve leaflets or the chords that attach the valve to the heart pumping chambers themselves are affected. In secondary tricuspid regurgitation the leaflets and chords themselves are not primarily affected, rather there is a process called annular dilation. The annulus is the ring like structure in between the upper and lower chambers of the heart that houses the valve. When the annulus enlarges, it stretches the valve leaflets cannot meet together, so they can no longer act as a valve, and therefore blood leaks backward.

Several things can cause primary tricuspid regurgitation, where the leaflets and/or chords are affected. These include valve infection, traumatic causes, birth defects and damage from pacemaker leads amongst other causes. Secondary tricuspid regurgitation is caused by factors leading to annulus enlargement, such as right ventricular failure or enlargement, or severely elevated pressures in the right side of the heart such as pulmonary hypertension. Even though the tricuspid valve is a right-sided heart structure, the most common cause of tricuspid regurgitation is actually left sided heart failure leading to congestion and subsequent right-sided problems!

Signs And Symptoms

When tricuspid regurgitation is severe it can lead to right sided heart failure and right-sided congestion. The degree of symptoms generally depends on how badly the right side of the heart is failing. In addition to shortness of breath, there can be weakness, swelling, liver dysfunction, fatigue and weight loss. The swelling is typically in the legs and can also be in the stomach in the end stages. When the right side of the heart fails badly, it affects the left side too which can lead to shock. Its like a cycle whereby left heart failure, can lead to right heat failure, that can worsen left heart failure, and so on.

Diagnosis

Until tricuspid regurgitation becomes severe its not easy to diagnose by physical exam. There is a heart murmur, and also the jugular vein in the neck can often seen to be pulsating prominently with a characteristic pattern. The gold-standard way to diagnose tricuspid regurgitation is an echocardiogram, an ultrasound scan of the heart. This test is known as a TTE, short for transthoracic echocardiogram.

The TTE is useful in not only grading the severity of the leakiness of the tricuspid valve, but also provides important information regarding the right sided heart pressures and the pumping function of the right ventricle. The TTE will also tell us the cause of the tricuspid regurgitation. Severe tricuspid regurgitation is typically leakiness of more than 45ml per beat. This is supported by signs of right-sided heart failure such as enlargement of the pumping chamber, and decreased pump function. There may also be elevation of the pulmonary artery pressures leading to pulmonary hypertension.

Mild Tricuspid Regurgitation

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Moderate Tricuspid Regurgitation

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Severe Tricuspid Regurgitation

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Treatment

There are no medicines that will improve the tricuspid valve itself or that have been proven to improve the right ventricular enlargement or failure associated with tricuspid valve disease. The management of severe tricuspid regurgitation is discussed in the section about surgery. In mild to moderate regurgitation, and even severe, it is important to treat the underlying cause. In general this means treating the left sided heart failure to try and reduce the congestion. Diuretics such as Lasix (furosemide) are typically used to take off excess water and try and improve symptoms. When pressures in the right side of the heart and lungs are severely elevated then treatments to reduce those may be somewhat helpful in reducing symptoms. It’s also important to treat conditions that can prevent further development of heart failure such as high blood pressure, sleep apnea, and obesity.

When Is An Operation Needed For Tricuspid Valve Regurgitation?

For years the tricuspid valve was relatively ignored, however over recent years it has gained much more attention. It is now realized that in many circumstances, delaying an operation on a severely leaky mitral valve leads to worse outcomes. As we discussed above, there is primary and secondary tricuspid regurgitation. The goal of an operation for tricuspid regurgitation is to improve symptoms, and prevent progressive failure of the right ventricle, the hearts right-sided pumping chamber.

Surgery for Primary Tricuspid Regurgitation

Primary tricuspid regurgitation is where there is a direct problem with the valve leaflets or associated chord strings. This only accounts for around 20% of severe tricuspid regurgitation. The majority of tricuspid regurgitation is secondary and due to left sided heart disease. In the case of primary tricuspid regurgitation, the primary operation will be on the tricuspid valve, unlike secondary tricuspid regurgitation where operations will typically be done on the left sided heart valve (the mitral valve) also. Surgery is recommended for primary tricuspid regurgitation when there is development of symptoms, or evidence of progressive enlargement and failure of the right ventricle. In the past we used to wait until there were severe symptoms, however now the trend is to operate when there is development of mild symptoms in order to prevent irreversible heart damage.

Surgery for Secondary Tricuspid Regurgitation

Secondary tricuspid regurgitation is where the problem isn’t with the valve leaflets, but rather due to enlargement of the heart and the structures that hold the valve in place. This is mainly due to left sided heart failure or left sided valve problems that lead to congestion and put higher pressure on the right ventricle and the right-sided tricuspid valve. The majority of people that present with severe tricuspid regurgitation have secondary tricuspid regurgitation. It used to be thought that the best way to treat the tricuspid regurgitation was to fix the left sided heart valve, i.e. the mitral valve. The thinking was that this would then relieve pressure on the right side of the heart, and the tricuspid regurgitation would improve. Over the years we realized that it was in-fact very difficult to predict whether an operation on the left sided heart valves would improve the tricuspid regurgitation, and also that the tricuspid regurgitation, although it may improve initially, would often recur. Due to this, the contemporary approach to tricuspid regurgitation is more aggressive. In general, when patients present for left sided valve surgery, such as aortic or mitral valve surgery, if there is severe TR then the tricuspid valve should be operated on at the same time. Some specialists would advocate for an even more aggressive approach and when doing left sided valve surgery, will operate on the tricuspid valve if there are lesser degrees of tricuspid regurgitation, particularly if there is evidence of valve enlargement. The decision depends on many factors that include surgical risk and should be made on a case-by-case basis by specialists familiar with tricuspid valve disease. In our center we frequently use robotic heart surgery to fix the tricuspid valve.

Frequently Asked Questions about Tricuspid Valve Replacement

Tricuspid Valve Repair or Tricuspid Valve Replacement?

In general the tricuspid valve should be repaired, and not replaced. Tricuspid valve replacement should be avoided unless absolutely necessary and it is not possible to perform tricuspid valve repair, or a previous tricuspid valve repair has failed. The preferred operation for tricuspid valve regurgitation is valve repair, whereby the original valve is kept in place and techniques used to fix it. Most commonly this consists of placement of sutures or a ring around the tricuspid valve to reduce it back to normal size and restore normal valve competency.

My Echocardiogram Report Showed Trace Tricuspid Regurgitation – Should I be Worried?

Trace tricuspid regurgitation basically means that only a tiny bit of blood leaks back in to the upper right chamber of the heart. The simple answer to the question is no you should not be worried. In fact trace tricuspid regurgitation is considered a normal finding. Having trace tricuspid regurgitation is actually useful for the physicians performing and interpreting the test, as we use this to calculate the pulmonary artery pressure. No treatment and no specific follow up are required for trace tricuspid regurgitation.

My Echocardiogram Report Showed Mild Tricuspid Regurgitation – Should I be Worried?

In general, no, there is no cause for concern. Mild tricuspid regurgitation is common. It does not cause symptoms or have an effect on the heart function. As with anyone, it’s important to treat usual cardiac risk factors and prevent the development of heart failure. In general, no specific follow up is required for mild tricuspid regurgitation.

My Echocardiogram Report Showed Moderate Tricuspid Regurgitation – What Should Be Done?

Moderate tricuspid regurgitation is not typically associated with any signs or symptoms. Isolated tricuspid regurgitation does not require any valve intervention unless there is an operation needed on the left sided (aortic or mitral) valves. In the case of just moderate tricuspid regurgitation, it’s important to treat ongoing cardiac risk factors such as hypertension. In terms of follow up, repeat echocardiography may be performed after an interval, to the leakiness hasn’t progressed to severe, and also to monitor the heart size and function.

References

European society of cardiology guidelines – http://eurheartj.oxfordjournals.org/content/33/19/2451.long

ACC/AHA guidelines – http://www.ncbi.nlm.nih.gov/pubmed/24603191

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