cardiovascular disorders
Tricuspid Regurgitation
Symptoms and Signs of Tricuspid Regurgitation
Tricuspid regurgitation usually causes no symptoms, but some patients experience neck pulsations due to elevated jugular pressures. Symptoms of severe TR include peripheral edema, fatigue, abdominal bloating, ascites, and anorexia. Patients may also develop symptoms of atrial fibrillation or Atrial Flutter . Signs of moderate to severe tricuspid regurgitation include jugular venous distention, with a prominent mergedc-vwave and a steepydescent, and sometimes enlarged liver and peripheral edema. In severe TR, a right jugular venous thrill may be palpable, as may systolic hepatic pulsation and an RV impulse at the left lower sternal border. Holosystolic murmur heard best at the left middle or lower sternal border (frequently not heard) On auscultation, the first heart sound (S1) may be normal or barely audible if a tricuspid regurgitation murmur is present; the second heart sound (S2) may be split (with a loud pulmonic component [P2] in pulmonary hypertension) or single because of prompt pulmonic valve closing with merger of P2 and the aortic component (A2). An RV third heart sound (S3) may be audible near the sternum with RV dysfunction–induced heart failure. The murmur of tricuspid regurgitation is frequently not heard. When evident, it is a holosystolic murmur heard best at the left middle or lower sternal border or at the epigastrium with the bell of the stethoscope when the patient is sitting upright or standing. The murmur may be high-pitched if TR is trivial and due to pulmonary hypertension, or it may be medium-pitched if TR is severe and has other causes. The murmur varies with respiration, becoming louder with inspiration (Carvallo sign). When the murmur is not present at all, the diagnosis is best made by the appearance of the jugular venous wave pattern and the presence of hepatic systolic pulsations. 