Tricuspid Valve Disease
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Direct answer
Tricuspid valve disease is most often functional regurgitation caused by right ventricular dilatation, usually from left-sided heart failure, atrial fibrillation or pulmonary hypertension. Its characteristic signs are a pansystolic murmur that increases with inspiration, the Carvallo sign, a large v wave in the jugular venous pulse and a pulsatile liver. Tricuspid stenosis, which is mostly rheumatic, produces a diastolic rumble that also rises with inspiration.
What you must remember
- Functional regurgitation: caused by right ventricular dilatation and the commonest form today; repair is often done alongside left-sided surgery when the annulus is dilated.
- Murmur: pansystolic at the lower left sternal edge and louder on inspiration (the Carvallo sign), the opposite of most left-sided murmurs.
- Tricuspid stenosis: a mid-diastolic rumble at the lower left sternal edge, enhanced by inspiration, most often rheumatic and usually with mitral disease.
- Venous pulse: prominent v waves with absent x descent in regurgitation, and a slow y descent in stenosis.
- Ebstein anomaly: apical displacement of the septal and posterior tricuspid leaflets with an atrialised right ventricle, linked to accessory pathways and prenatal lithium exposure.
- Carcinoid heart disease: serotonin causes plaque-like fibrosis of right-sided valves, producing tricuspid regurgitation and pulmonary stenosis.
- Endocarditis: injection drug use typically infects the tricuspid valve, shedding septic emboli into the lungs.
- Surgery: repair is preferred where feasible, with replacement when the leaflets are destroyed.
Sorting a murmur that grows with breathing
A 58-year-old woman with long-standing mitral stenosis and atrial fibrillation has a soft pansystolic murmur at the lower left sternal edge that is louder on inspiration. Her jugular pulse shows a giant v wave, and her liver is enlarged and pulsatile.
- Separate the murmurs: The first job is to distinguish this from other right-heart murmurs and decide whether the valve needs intervention.
- Read the breathing response: The Carvallo sign points to regurgitation, because a right-sided murmur strengthens on inspiration as more blood enters the right heart. A diastolic rumble with the same respiratory response would indicate tricuspid stenosis instead.
- Confirm with echo: The echo confirms the diagnosis, assesses right ventricular size and function, estimates pulmonary pressure and measures the annulus.
- Treat the cause first: Because the regurgitation is functional, the early aim is rate control for atrial fibrillation, diuretics for congestion and attention to the mitral valve.
- Consider repair: Tricuspid repair is considered if the regurgitation is severe with annular dilatation, usually during mitral surgery, since isolated treatment of functional regurgitation carries less certain benefit.
Where the examiner tests the direction of the sign
Respiratory direction and look-alike lesions drive most tricuspid questions.
- Trap: Expecting every murmur to soften on inspiration. Correct: Left-sided murmurs generally soften on inspiration because venous return to the left heart falls, while right-sided murmurs strengthen.
- Trap: Confusing Ebstein anomaly with tricuspid stenosis or an atrial septal defect. Correct: Ebstein anomaly shows apical displacement of the septal leaflet, a large atrialised right ventricle and an association with pre-excitation.
- Trap: Assuming carcinoid causes only right-sided valve disease. Correct: A stem with left-sided lesions and a patent foramen ovale tests the reason, because serotonin normally inactivated in the lungs reaches the left heart through the shunt.
- Trap: Attributing tricuspid endocarditis to systemic emboli. Correct: A young injecting drug user with fever and a tricuspid vegetation has septic pulmonary emboli rather than systemic ones.
Frequently asked questions
What distinguishes tricuspid regurgitation from tricuspid stenosis?
Tricuspid regurgitation gives a pansystolic murmur with a prominent v wave, while stenosis gives a mid-diastolic rumble with a slow y descent. Both murmurs increase with inspiration, so the timing and venous pulse matter more than breathing alone.
What is the Carvallo sign?
The Carvallo sign is the inspiratory increase in intensity of the tricuspid regurgitation murmur. It supports a right-sided origin, because right-sided murmurs strengthen on inspiration.
What are the main features of Ebstein anomaly?
Ebstein anomaly shows apical displacement of the septal and posterior tricuspid leaflets, with an atrialised right ventricle. It is associated with accessory pathways and with prenatal exposure to lithium.
How does carcinoid affect the tricuspid valve?
Carcinoid heart disease produces plaque-like fibrosis of right-sided valves, causing tricuspid regurgitation and pulmonary stenosis. Left-sided lesions are uncommon and mainly appear when serotonin bypasses the lungs, typically through a right-to-left shunt such as a patent foramen ovale.
Why do tricuspid valve infections cause pulmonary emboli?
Right-sided vegetations, typically in injecting drug users, shed septic fragments into the pulmonary circulation. This produces septic pulmonary emboli rather than systemic ones, and the chest imaging often shows cavitating lesions.