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Tricuspid
Regurgitation

Tricuspid Regurgitation (TR) is a complex disease that has multiple causes, and is associated with high rates of morbidity and mortality.1,2 TR is highly prevalent, and among valve diseases, is one of the most undertreated.1,3 If left untreated, TR initiates a cascade of events that can lead to right-sided Heart Failure (HF) and death.4

Most early-stage TR is clinically silent,1 and even with severe TR, some patients may be asymptomatic.27 In patients who become symptomatic of TR, the prevalence and severity of the symptoms are greater in patients with more severe TR.7,8,28–30

The symptoms of TR (when present) include:18,20

Shortness of Breath
Fatigue
Peripheral Oedema
AFIB
Chest pain
DizzinesS
Fainting

In patients with severe TR or advanced right-side HF and therefore poor cardiac function, these symptoms may include decreased cardiac output, right atrial hypertension, fluid retention (peripheral or pulmonary), dyspepsia, ascites, or indigestion.13,31

TR can cause or aggravate the signs and symptoms of HF,32 and symptomatic patients with TR commonly present with the symptoms of HF, and not the TR itself.13,20,33
 

Key cardiac and non-cardiac comorbidities associated with TR


CARDIAC COMORBIDITIES

  • Reduced Left Ventricular Ejection Fraction (LVEF), moderate/severe Mitral Regurgitation (MR), and AF are common comorbidities in patients with TR.7,8,28–30
  • Severe secondary TR may cause HF and is associated with heart transplant and Valvular Heart Disease (VHD).8,34
  • Severe secondary TR is significantly (p<0.001) associated with pulmonary hypertension.34
     

NON-CARDIAC COMORBIDITIES

  • Patients with TR commonly suffer from diabetes mellitus, chronic kidney disease, or dyslipidaemia.35,36
  • Severe TR can also lead to liver and renal impairment.37


Abbreviations: AF, atrial fibrillation; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; TR, tricuspid regurgitation; VHD, Valvular Heart Disease.

VHD may be detected incidentally during patient examinations, such as the presence of heart murmur during a physical examination, or heart valve abnormalities on chest imaging or non-invasive testing (i.e. echocardiography)28,33,36,38

 

Methods for diagnosis and assessment of TR
 

CHEST X-RAY

  • Determine the presence or absence of pulmonary congestions/other lung pathologies which may be present in patients with VHD.19
  • Chest X-ray is also used to identify cardiomegaly of the right-side heart, however there are no specific findings that would indicate TVD.13
     

ELECTROCARDIOGRAPHY (ECG)   

  • ECG is used to investigate the heart rhythm and identify if AF is present.19
  • Elevated right atrial pressure with “c-V” wave is indicative of severe TR.19
     

ECHOCARDIOGRAPHY     

  • Echocardiography is the key technique used to confirm the diagnosis of VHD, as well as to assess its aetiology, mechanisms, function, severity, and prognosis.39
  • Echocardiography is typically used in assessing both the mechanism and severity of TR.31
  • TransThoracic Echocardiography (TTE) can distinguish between primary and secondary TR, identify comorbid LSHD, and estimate pulmonary artery systolic pressure.19
  • In the presence of TR, tricuspid valve analysis is mandatory; two-dimensional (2D)-TTE imaging is the technique of choice. Three-dimensional (3D)-TTE can be used as an additive approach.33
  • TransoEsophageal Echocardiography (TEE) is advised in case of suboptimal TTE images. Distinction between primary and secondary TR is warranted.33
  • TEE can also be used during transcatheter procedures, to guide the device into the correct position.40


COLOUR FLOW DOPPLER

  • Colour flow imaging can identify small regurgitant jets (jets of backward flowing blood), and can be used to diagnose TR, however it is not recommended to assess TR severity.33


COMPUTED TOMOGRAPHY (CT) IMAGING   

  • CT can provide a detailed image of the valve anatomy, especially of the systolic and diastolic ventricle geometry. This information is key for pre-procedural planning of a catheter-based intervention.41,42

CARDIOVASCULAR MAGNETIC RESONANCE (CMR) IMAGING

  • CMR imaging is typically used as a test for evaluating RV function.43

  • Although CMR assessment of TR is feasible, it is less established than for other valves.44

  • Patients with inadequate echocardiography may receive CMR imaging to assess the severity of valvular lesions, ventricular volume, or systolic function, thus CMR can aid the evaluation of TR severity.39


Abbreviations: 2D, two-dimensional; 3D, three-dimensional; AF, Atrial Fibrillation; CMR, Cardiovascular Magnetic Resonance; CT, Computed Tomography; ECG, ElectroCardioGraphy; LSHD, Left-Sided Heart Disease; RV, Right Ventricular; TR, Tricuspid Regurgitation; TEE, Transoesophageal Echocardiography; TTE, Transthoracic Echocardiography; TVD, Tricuspid Valve Disease; VHD, Valvular Heart Disease.

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