Tricuspid Regurgitation

Causes

Tricuspid regurgitation has many possible causes. In adults, the most common cause is another health condition. In younger people (who make up about 15 to 30% of patients), it's often due to a defect in the tricuspid valve that they were born with.

Health conditions that can cause tricuspid regurgitation include lung problems, such as chronic obstructive pulmonary disease (COPD) or a clot that has traveled to the lungs (a pulmonary embolism). Heart problems, including a weaker left side of the heart and problems with other valves, can also lead to tricuspid regurgitation. These health issues can strain the heart, enlarge the right ventricle and stretch out the valve, making it leaky.

Conditions that can lead to tricuspid regurgitation in young people include congenital heart defects, such as Ebstein anomaly, or other congenital conditions, including connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome.

Other things that can damage the tricuspid valve and cause regurgitation include infections, rheumatoid arthritis, radiation therapy, carcinoid tumors, and a history of using the diet pill fen-phen (fenfluramine and phentermine).

Signs & symptoms

The tricuspid valve separates the heart's upper right chamber (atrium) from its lower right chamber (ventricle), which pumps blood to the lungs, where it picks up oxygen. Tricuspid regurgitation happens when the tricuspid valve doesn't close tightly. Each time the right ventricle contracts, the leaky valve lets a small amount of blood flow backward into the right atrium. As a result, blood flow to the lungs is less efficient than it should be.

Mild tricuspid regurgitation may not cause any symptoms. With more significant regurgitation, the heart works harder to pump, which can lead to heart failure. Symptoms of heart failure include:

• Pulsing neck veins
• Reduced urine output
• Feeling tired and weak
• Swollen feet and ankles
• Pain and swelling in the abdomen
• Digestive issues, such as nausea and loss of appetite
• Shortness of breath
• Reduced ability to exercise

Diagnosis

If your doctor suspects you have tricuspid regurgitation, the first step is a physical exam to check for signs. You'll also undergo tests to evaluate your heart, including the valves, and determine the severity of your condition. These may include:

• Electrocardiogram (ECG). This painless test measures the heart's electrical activity. It can detect enlarged heart chambers, heart disease and abnormal heart rhythms.
• Heart CT scan. This uses X-rays to create detailed images of the heart's structures and blood vessels.
• Heart MRI. Using radio waves and a powerful magnet, this test provides exceptionally detailed images of structures in the heart.
• Doppler or regular echocardiogram. An echocardiogram is an ultrasound of the heart. The addition of Doppler technology shows blood flow through the chambers and valves, allowing doctors to assess leakage through the faulty valve.
• Right heart catheterization. Also called Swan-Ganz catheterization, this test involves passing a catheter (a thin, flexible tube) into a blood vessel and up to the right side of the heart and the arteries leading to the lungs. It's used to evaluate how well the heart is pumping and to measure blood pressure and blood oxygen levels in the heart and lungs.

Treatment

Treatment of tricuspid regurgitation depends on the cause and the condition's severity. If you have few or no symptoms, you may not need treatment, but your doctor will monitor your heart status with regular appointments. Some people live for years without their leaky valve worsening and causing symptoms.

In other patients, the overworked heart enlarges, stretching out the valve and worsening the leak over time. These patients require active treatment.

Medical therapies

If you have symptoms from a leaky tricuspid valve, your doctor will first try to treat them with medication. If an underlying condition is causing the regurgitation, medications for that condition may resolve the valve problem. These include medications to reduce blood pressure in the lungs or reduce swelling of the ventricle.

If a structural defect caused the regurgitation, you may need additional medications to relieve symptoms, such as fatigue and swelling, and reduce the risk of complications from tricuspid regurgitation. They won't fix the malfunctioning valve, but they may slow symptom progression.

These medications include:

• Diuretics. These drugs relieve swelling by removing excess fluid from the body.
• ACE (angiotensin-converting enzyme) inhibitors. These medicines relax veins and arteries, reducing blood pressure and strain on the heart.
• Aldosterone antagonists. A type of diuretic, these drugs make the kidneys remove extra water and salt from the body, which relieves swelling.
• Antiarrhythmics. These medicines control abnormally fast heart rhythms to reduce strain on the heart.
• Anticoagulants. These drugs lessen blood's ability to clot, lowering the risk of stroke.

Surgical options

For severe tricuspid regurgitation, surgery to treat the leaky valve is necessary. Surgeons often combine tricuspid valve surgery with another procedure. For example, if the patient is having surgery to repair or replace another heart valve, the doctor may recommend repairing or replacing the tricuspid valve at the same time, even if the tricuspid regurgitation is mild or moderate.

Surgical treatments include:

• Annuloplasty. This surgery tightens, remodels or reinforces the ring around the valve.
• Valve repair. Surgeons reshape or remove extra tissue so that the valve can close properly.
• Valve replacement. A mechanical valve or one made from human, cow or pig tissue is substituted for the leaky valve.

Traditionally, these procedures have been done as open-heart surgeries, which require a long incision, cracking the breastbone and temporarily stopping the patient's heart (while using a heart-lung bypass machine to keep blood flowing through the body). Open-heart patients typically stay in the hospital for a week and have a prolonged recovery.

Newer approaches use minimally invasive, catheter-based techniques to repair or replace the defective heart valve. These transcatheter heart procedures use a wire threaded through veins or arteries. They are less painful, require a shorter hospital stay and allow for a faster recovery. For patients with hearts of specific sizes and shapes, they can be a less risky option.

Multiple types of catheter-based devices for treating severe tricuspid regurgitation have either been approved by the Food and Drug Administration (FDA) or are currently being evaluated in clinical trials. Certain patients may be eligible to enroll in clinical trials of leaky valve treatments taking place at UCSF.