Heart disease: tricuspid insufficiency (tricuspid regurgitation)

By Cristiano Antonino On May 24, 2023

Tricuspid insufficiency is a heart disease characterised by regurgitation of blood within the right atrium during the contraction phase of the heart (systole)

It is due to a defect in the tricuspid valve, one of the four cardiac valves responsible for maintaining unidirectional blood flow within the myocardial muscle: in patients with this disorder, it does not close properly, leading to a decrease in cardiac output, which consists of a reduction in the heart’s ability to pump oxygenated blood to all organs and tissues of the body.

In most cases, tricuspid insufficiency presents itself asymptomatically

However, it is a condition that should not be underestimated, as it can pose even serious risks to the patient’s health.

The main causes of its onset are linked to the presence of pulmonary pathologies or heart disease.

In addition, tricuspid insufficiency can be due to congenital malformations, infections or thoracic trauma

Depending on the nature of the disorder, treatment may involve drug therapy or, in more severe cases, surgery may be necessary.

Anatomy of the heart

To better understand the function of the tricuspid valve, and the effects of associated disorders, it may be useful to briefly review some of the main anatomical features of the heart.

The internal conformation of the heart muscle is divided into two halves: a right and a left side; each of the two compartments consists of two cardiac cavities within which blood flows, namely the atria and the ventricles.

The atria and ventricles on each side are separated by laminar membranes, which are called the interatrial septum and the interventricular septum.

The atrium and ventricle of the same half are placed one above the other respectively and are connected by special valves, called atrioventricular valves: the tricuspid valve, on the right side of the heart, regulates the flow of blood from the right atrium to the right ventricle, while on the left side is the mitral valve, which controls the flow of blood from the left atrium to the left ventricle; their main function is to ensure unidirectional blood flow, through a hermetic closure mechanism that prevents blood regurgitation within the atrium when the heart contracts.

In the right ventricle is the pulmonary semilunar valve, which allows the blood to flow to the pulmonary artery, where it is loaded with oxygen once it reaches the lungs. In the left ventricle is the aortic semilunar valve, which regulates the flow of blood to the aorta, the main artery of the human body, which is responsible for the distribution of oxygenated blood to the body.

Although the blood flow within the heart cavities is separate, the right and left hearts contract in a coordinated manner: first the atria, then the ventricles.

The movements necessary for the heart to pump blood are called systole (contraction phase) and diastole (relaxation phase).

What is tricuspid insufficiency?

As already mentioned, the tricuspid valve is located in the orifice between the atrium and the right ventricle and helps regulate the unidirectional flow of blood within the right heart.

Its structure consists of:

Valve ring, which is the orifice of the valve.
Three flaps, or cusps (hence the name), on which specific anatomical structures are placed to close the orifice.
Papillary muscles, which are extensions of the myocardial muscle.
Ropes of tendon, which connect the valve leaflets with the papillary muscles.

The valve’s opening and closing mechanism depends on the pressure gradient, i.e. the difference in pressure between the atrium and ventricle during the contraction and relaxation phases of the heart muscle.

In some cases, abnormalities in the closing mechanism of the tricuspid valve may occur, due to which blood tends to reflux into the atrium; the increase in blood volume within the atrial cavity results in a decrease in ejection volume and cardiac output.

In addition, due to blood regurgitation, the atrium has to handle a greater amount of blood and its walls tend to thicken and dilate (atrial hypertrophy).

In order to perform its task, the heart increases its exercise pressure and is therefore placed under continuous strain; this leads to a high risk of arrhythmic phenomena such as atrial fibrillation or flutter, and the development of serious heart failure.

The altered morphology of the right atrium further favours incomplete valve closure, worsening the clinical picture.

This condition is called tricuspid insufficiency, and is one of the main disorders that can affect the right side of the heart.

Specifically, disorders affecting the heart valves are called valvulopathies

In addition to insufficiency, another of the main valvulopathies affecting the tricuspid valve is tricuspid stenosis: this is a condition characterised by the narrowing of the valve orifice, resulting in a decrease in the amount of blood pumped by the heart, which is often associated with insufficiency conditions.

What can be the causes of onset?

Unlike other cardiac valvulopathies, tricuspid insufficiency generally affects a normal valve, the function of which may, however, be impaired by other pathological disorders.

In this regard, two distinct forms can be distinguished according to the nature of the pathology: a primary insufficiency of the tricuspid valve and a secondary insufficiency.

Primary tricuspid insufficiency: this is a less frequent form of the disorder, in which the insufficiency is caused by defects of congenital origin, cardiac malformations such as a cleft tricuspid valve or idiopathic myxomatous degeneration, or hereditary diseases such as Marfan syndrome or Ebstein’s anomaly; primary insufficiency can also be the result of serious infectious processes, such as endocarditis or rheumatic fever. In addition, it may be due to taking certain drugs, violent chest trauma or carcinoid syndrome.
Secondary tricuspid insufficiency: this is the most common form of the disorder, and usually involves patients suffering from pathological disorders that can lead to a weakening of the heart muscle; the most common causes of its onset are dilatation of the right ventricle, heart disease on the left side of the heart, other associated valvulopathies, a pulmonary stenosis, or other lung diseases such as emphysema or hypertension.

What are the main symptoms

As already mentioned, in most cases tricuspid insufficiency presents itself asymptomatically.

In fact, although it is a condition that can lead to very serious complications, it is generally, at least initially, well tolerated by the patient, who may experience the first symptoms several years after the onset of the condition.

In its early stages, tricuspid insufficiency presents itself in a mild manner, with minimal blood regurgitation, but it is characterised by a progressively degenerative course that, in the long run, can compromise the functioning of the entire cardiac system.

Symptomatology is usually rather vague and may include:

high pulsation felt in the neck or feeling of a heart in the throat
feeling of fatigue and weakness;
symptoms of atrial fibrillation or atrial flutter;
inability to perform physical exertion;
exertional dyspena or difficulty breathing;
angina pectoris i.e. chest pain;
oedema formation in the lower limbs;
abdominal swelling;
occasionally hepatomegaly, i.e. enlargement of the liver;
venous stasis or swelling of the legs;
in severe cases syncope or presyncope.

Diagnosis

Due to the almost asymptomatic nature of tricuspid insufficiency, the diagnosis of this condition may not be immediate and requires a careful cardiological examination to detect.

A distinctive sign of valvulopathy may be the presence of a heart murmur, caused by turbulence of blood reflux through the tricuspid valve and detectable by auscultation.

During the check-up, the cardiologist first carries out an objective test, assesses the symptoms reported by the patient and analyses the personal and family history to identify previous or current pathologies that may lead to heart muscle disorders.

At the end of the examination, the doctor may prescribe some specific tests, such as:

Electrocardiogram (ECG)
Echocardiography
Echo-colour-Doppler
Magnetic resonance imaging (cardiac MRI)
Chest X-ray (chest X-ray)
If necessary, cardiac catheterisation
Care and treatment of tricuspid insufficiency

As already pointed out, patients with tricuspid insufficiency can take a long time before showing symptoms; in the case of mild valvulopathy, no treatment is generally necessary, but it is very important to constantly monitor the condition with regular cardiological examinations.

In the case of insufficiency due to other pathological disorders, on the other hand, it is necessary to intervene to resolve the triggering condition.

When the valvulopathy worsens and leads to severe decompensation, it may be necessary to intervene surgically to restore proper functioning of the tricuspid valve.

Treatment options include:

Anuloplasty: aims to reduce the diameter of the valve ring by suturing prosthetic devices to encourage cusp adhesion.
Valve repair: often allows malformations and malfunctions of heart valves to be corrected. It can be performed minimally invasively via catheterisation, or by means of surgery. The operation can usually involve the valve leaflets or the chordae tendineae.
Valve replacement: when none of the previous operations are feasible, it is necessary to remove the diseased valve and replace it with a mechanical or bioartificial type.

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