Tricuspid Valve Disease

How the tricuspid valve works

The tricuspid valve has three leaflets and sits between the right atrium and right ventricle. It opens to let blood from the body flow into the right ventricle, then closes as the ventricle pumps blood to the lungs. If it leaks, blood flows backward into the right atrium and the veins, raising pressure in the liver, belly and legs.

Types

Tricuspid regurgitation (TR)

• Secondary (functional) TR: about 80 to 90 percent of cases. The valve is normal, but the right ventricle or annulus (ring) is stretched by: - left-sided heart disease such as heart failure or mitral valve disease - pulmonary hypertension - long-standing atrial fibrillation
• Primary TR: the valve itself is damaged: - pacemaker or defibrillator leads crossing the valve - endocarditis, especially in people who inject drugs - carcinoid syndrome - rheumatic heart disease - Ebstein anomaly (a congenital defect) - chest trauma and some medicines

Trace or mild TR is found on echocardiograms in many healthy people and is normal.

Tricuspid stenosis (TS)

Rare in developed countries. Usually caused by rheumatic fever, almost always with mitral valve disease, or by carcinoid syndrome.

Symptoms

Mild disease usually causes no symptoms. Moderate to severe disease can cause:

• swelling of the legs and ankles
• a swollen belly (fluid, ascites) and weight gain
• fatigue and reduced exercise ability
• breathlessness, often from the underlying left heart or lung disease
• a pulsing sensation in the neck
• discomfort or fullness in the upper right belly from an enlarged liver
• loss of appetite and nausea
• palpitations from atrial fibrillation

Diagnosis

• physical exam: a murmur that increases with breathing in, raised neck veins, enlarged pulsating liver, leg swelling
• echocardiogram: confirms the problem, grades severity, measures right heart size and function, and estimates lung pressures
• ECG and chest X-ray
• cardiac MRI or CT to assess right ventricle size and plan procedures
• right heart catheterization to measure pressures in some cases
• blood tests: liver and kidney function, BNP

Severity is graded from trace and mild to moderate, severe, massive and torrential.

Treatment

Monitoring

Mild to moderate TR without symptoms is monitored with periodic echocardiograms.

Medicines

• diuretics (water pills) to reduce swelling and fluid
• treatment of the cause: heart failure medicines, therapies for pulmonary hypertension, rhythm or rate control for atrial fibrillation
• antibiotics for endocarditis

Surgery

Guidelines recommend tricuspid surgery for severe TR at the time of left-sided valve surgery, and consider it for:

• severe TR with symptoms
• progressive right ventricle enlargement
• moderate TR with an enlarged annulus during left-sided valve surgery

Options include annuloplasty (a ring to tighten the valve), repair, or replacement with a mechanical or tissue valve.

Transcatheter therapies

For people at high surgical risk, catheter-based procedures can reduce TR without open surgery. These include edge-to-edge repair devices and transcatheter tricuspid valve replacement, which became available in the US in recent years.

Tricuspid stenosis

Treated with diuretics, and balloon valvotomy or surgery in selected cases.

Complications

• right-sided heart failure
• atrial fibrillation
• liver congestion and, over time, cirrhosis (cardiac cirrhosis)
• kidney dysfunction
• malnutrition and muscle wasting

Outlook

Mild TR has an excellent outlook. Severe TR is linked to worse survival, especially when left untreated until the right ventricle fails, which is why earlier evaluation and intervention are increasingly recommended.

Frequently asked questions

Is mild tricuspid regurgitation normal?

Yes. Trace or mild tricuspid regurgitation is seen on echocardiograms in many healthy people and usually needs no treatment or follow-up. It becomes significant only when moderate or severe.

What causes tricuspid regurgitation?

Most cases are caused by enlargement of the right side of the heart due to left-sided heart disease, pulmonary hypertension or atrial fibrillation. Less commonly, the valve itself is damaged by pacemaker leads, endocarditis, carcinoid syndrome or rheumatic disease.

What are the symptoms of severe tricuspid regurgitation?

Leg and ankle swelling, a swollen belly, fatigue, poor appetite, discomfort under the right ribs and a pulsing feeling in the neck. Breathlessness is common when there is underlying heart or lung disease.

How is tricuspid valve disease treated?

Mild disease is monitored. Diuretics reduce swelling, and the underlying cause is treated. Severe disease may need surgical repair or replacement, or a catheter-based procedure in people at high surgical risk.