Tricuspid regurgitation assessment

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Etiology of tricuspid regurgitation

The presence of mild tricuspid regurgitation (TR) is physiologic in 65-100% of the population. More than mild regurgitation is abnormal and is suspicious for tricuspid valve disease:


  • Functional tricuspid regurgitation

Functional TR is the most frequent etiology. It is secondary to poor tricuspid leaflets coaptation due to dilatation of tricuspid annulus and right chambers.

  • Organic tricuspid regurgitation

Organic tricuspid regurgitation can be due to

-rheumatic heart disease

-endocarditis (IV drugs)

-congenital heart disease (Ebstein)

The patient's history and the two-dimensional assessment of the valve will be useful in these cases.

  • Iatrogenic tricuspid regurgitation
    The presence of pace-maker or intra-cardiac defibrillator, as well as repeated right ventricle biopsies (transplanted patients) lead to tricuspid trauma and TR.


Assessment of tricuspid regurgitation

 

Mechanisms of regurgitation: patient's history and two-dimensional echocardiography

The observation of the tricuspid valve in two-dimension images, from parasternal long axis right chamber view and apical 4 chamber view, will give some indications on the mechanism of regurgitation:

TR rheumatic A4C color.jpg
-rheumatic heart disease: the valve will be thickened and restricted. It is very important to look for associated tricuspid stenosis and other valves involvement. On this apical 4 chamber view, you can see the thickening of the tricuspid valve, and the moderate tricuspid regurgitation (blue-yellow color flow) 






TR endocarditis A4C.jpg
-endocarditis: visualization of a vegetation appended to the atrial side of the valve, vibratile in the right atrium. On this apical 4 chamber view, you can see a large mass appended to the tricuspid valve.






Ebstein A4C.jpg
-congenital heart disease: in Ebstein anomaly, the septal leaflet of the tricuspid valve will be apically displaced, with lack of coaptation with other leaflets. On this apical 4 chamber view, you can see the apical displacement of the septal tricuspid leaflet, which is 2cm more apical than the anterior mitral leaflet. 






ICD RV A4C.jpg
-visualization of pace-maker or ICD leads will oriente toward an iatrogenic cause








Color-Doppler imaging: severity of regurgitation

Tricuspid regurgitation will appear as a systolic jet going from RV to RA(blue jet in all views).

Parasternal long axis, right chamber view. There is moderate TR (blue-yellow systolic jet)
   Apical 4 chamber view. There is moderate excentric TR directed toward the inter-atrial septum:


Color Doppler imaging is used to quantify tricuspid regurgitation in the same manner than for mitral regurgitation.

Please go to the images library for examples of tricuspid regurgitation


Tricuspid regurgitation for calculation of right ventricle systolic pressure

With continuous Doppler across the tricuspid valve, guided by color Doppler, you can measure the systolic pressure gradient between RV and RA, using Bernouilli law. RA pressure is estimated with the diameter and respiratory variations of the IVC. The sum of RA pressure and gradient of pressure between RV and RA gives the RV pressure.

For more details, please read the chapter calculation of right ventricle pressure in the hemodynamics section.

 

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