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Chapter 2: Rheumatic fever and valve disease 47

ventricular failure, often with accompanying regurgita- Aetiology
tion of the tricuspid valve and signs of right-sided heart Tricuspid regurgitation can be divided into functional,
failure. i.e. secondary to dilation of the right ventricle, and or-
ganic tricuspid regurgitation:
Functional tricuspid regurgitation occurs with cor

Clinical features pulmonale, right-sided myocardial infarction or pul-
Severe pulmonary obstruction leads to right-sided heart monary hypertension.
failure in the first few weeks of life. Patients with mild Organic tricuspid regurgitation occurs with rheuma-
pulmonary stenosis are asymptomatic (diagnosed inci- tic mitral valve disease, infective endocarditis and the
dentally from the presence of a murmur or the presence carcinoid syndrome. Infective endocarditis affecting
of right ventricular hypertrophy on the ECG). Patients the tricuspid valve is seen particularly in intravenous
mayhavenon-specificsymptomssuchasfatigueordysp- drug abusers. Ebstein’s anomaly is a congenital dys-
noea. Syncope is a sign of critical stenosis, which requires plasia of the tricuspid valve with abnormal valve
urgent treatment. cusps and a downward malpositioning of the valve.
On examination a large ‘a’ wave may be seen in the
JVP (see page 27). Auscultation reveals a click and harsh Pathophysiology
mid-systolic ejection murmur heard best on inspiration Regurgitation of blood into the right atrium during sys-
in the left second intercostal space often associated with tole results in high right atrial pressures and hence right
a thrill. A left parasternal heave may also be felt due to atrial hypertrophy and dilatation. Volume overload re-
rightventricular hypertrophy. sults in an initial increase in right ventricular stroke vol-
ume (Starling’s mechanism) until decompensation oc-
curs, after which there is a reduction in cardiac output
Investigations
and signs of right-sided heart failure.
Chest X-ray may show a prominent pulmonary artery

due to post-stenotic dilation.
Clinical features
ECG may reveal right ventricular strain or hypertro-

Patients may present with symptoms and signs of right-
phy indicating the degree of stenosis.
sided heart failure such as ankle oedema, fatigue and
Echocardiography is used to examine and quantify

ascites. On examination a prominent V (systolic) wave
the flow across the stenosed valve. It is also essential to
may be seen in the JVP (see page 27) and a pulsatile
identifyanyassociatedcardiaclesionssuchastetralogy
enlarged liver may be palpable. A right ventricular heave
of Fallot. Assessment of right ventricular function is
maybefeltattheleftsternaledge.Onauscultationthereis
essential.
a pansystolic murmur, which unlike mitral regurgitation
Cardiac catheterisation may be used to assess the level

is accentuated by inspiration heard best at the left lower
and degree of the stenosis.
sternal edge.
Management Complications
Mild stenosis does not require treatment. In more severe Atrial fibrillation is very common. In the chronic un-
cases intervention is required before decompensation of treated patient there can be hepatic cirrhosis from the
the right ventricle occurs. Balloon dilatation has more or pressure effect on the liver.
less replaced the need for surgery except in the context
of more complex congenital heart disease. Investigations
The chest X-ray may show right atrial and ventricular
enlargement. Echocardiography is diagnostic and is also
essential to assess right ventricular function.
Tricuspid regurgitation
Definition Management
Retrograde blood flow from the right ventricle to the Functional tricuspid regurgitation usually resolves with
rightatrium during systole. management of heart failure. Severe organic tricuspid