Right Heart Disease

Tricuspid regurgitation that is medically significant can have two general kinds of underlying causes. First, the valve itself can become damaged because of some disease process. Second, the valve itself may be normal, but it can become leaky because an underlying cardiac problem has caused the heart to become dilated, so that the tricuspid valve can no longer close normally.

Medical conditions that can damage the tricuspid valve itself include:

• Rheumatic heart disease
• Infectious endocarditis
• Myocardial infarction affecting the right ventricle
• Myxomatous degeneration of the valve (similar to MVP)
• Injury from a pacemaker or implantable defibrillator lead2
• Marfan syndrome
• Carcinoid syndrome
• Congenital heart disease

The most common cause of tricuspid regurgitation, by far, is a “functional’ disturbance of the tricuspid valve, where the valve itself is essentially normal — but leakage occurs because a heart disorder of some kind distorts the heart. This most commonly happens because the right atrium or the right ventricle become dilated in a way that prevents the tricuspid valve from closing completely.

Heart problems that commonly cause functional tricuspid regurgitation include:

• Pulmonary artery hypertension
• Heart failure
• Mitral stenosis or mitral regurgitation
• Pulmonary embolism
• Hyperthyroidism

Most people with significant tricuspid regurgitation will turn out to have a functional valve disorder produced by one of these conditions. A full cardiac evaluation will be required to identify the nature and severity of the underlying problem, and to determine the best way of treating it.

The large majority of people with tricuspid regurgitation have no symptoms that can be attributed to the valve disorder 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 directly produce symptoms.

These symptoms may include :

• an uncomfortable feeling of an unusual pulsation in the neck,
• or abdominal pain and edema (swelling).
• If right-sided heart failure develops, pronounced dyspnea (shortness of breath), weakness and dizziness may occur.

But even with severe tricuspid regurgitation, symptoms are usually caused more by the underlying cardiac disorder than by the regurgitation itself.

TAKEAWAY

While most people with tricuspid regurgitation have a very mild condition that requires no treatment, sometimes it can be a serious matter. So if you are told you have tricuspid regurgitation, the first order of business is for your doctor to determine the underlying cause and the severity of the condition.

Tricuspid regurgitation is diagnosed with an echocardiogram. The two key questions after tricuspid regurgitation is diagnosed ought to be:

• What is the underlying cause?
• How severe is it?

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

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 usually have tricuspid valves that are fundamentally normal, 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 their physical activity. The only real “management” is periodic re-evaluations with a cardiologist.

Surgery should become an option if the tricuspid regurgitation itself is judged to be causing significant symptoms. In general when surgery is needed, whenever it is feasible repair of the tricuspid valve is preferred over valve replacement.