Tricuspid regurgitation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

On examination, the jugular venous pressure is usually elevated, and 'CV' waves can be seen. The liver may be enlarged and is often pulsatile (the latter finding being virtually diagnostic of tricuspid insufficiency). Peripheral edema is often found. In severe cases, there may be ascites and even cirrhosis (so-called 'cardiac cirrhosis). Tricuspid insufficiency may lead to the presence of a pansystolic heart murmur. Such a murmur is usually of low frequency and it is best heard on the left sternal border. It tends to increase with inspiration. However, the murmur may be inaudible reflecting the relatively low pressures in the right side of the heart. A third heart sound may also be present.

Physical Examination

Clinical findings in patients presenting with tricuspid regurgitation is usually as a result of right sided heart failure and regurgitant blood flow across the tricuspid valve into the right atria during ventricular contraction. Patients with right sided heart failure may present with peripheral edema, cyanosis, hepatosplenomegaly, ascitis, cachexia and jaundice. Signs of left-sided heart failure will dominate in case of left ventricular dysfunction.

Neck

• JVP is prominent and jugular venous distention is present.
• "V wave" is prominent as a result of systolic regurgitation into right atrium and it increases with inspiration.
• Severe regurgitation can also present as systolic thrill over the jugular vein.

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Heart

Palpation

• Right ventricular heave or lift may be present due to right ventricular enlargement.
• In the presence of pulmonary hypertension, dilated pulmonary artery may result in pulsations felt over the left second intercostal space.

Auscultation

Heart Sounds

• "S3 gallop" is present because of right ventricular dilation.
• Fourth heart sound (S4) may be present because of right ventricular hypertrophy.
• Pulmonic component of second heart sound (P2) is accentuated if pulmonary hypertension is present.
• Splitting of second heart sound (S2) may be notable if pulmonary hypertension is present.

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Murmurs

• Holosystolic murmur is present.
• Best heard at the right or left fourth intercostal space.
• In presence of right ventricular enlargement, murmur is even audible at the cardiac apex.
• Inspiration, leg raising, exercise and hepatic compression increases the intensity of the murmur by increasing venous return to the heart.
• Standing, amyl nitrate and valsalva maneuver decreases the murmur intensity by decreasing the venous return to the heart.
• A diastolic rumble may be present because of the increased blood flow across the tricuspid valve during diastole.

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Liver

• Hepatomegaly may be present.
• A thrill may be present due to the transmission of the systolic murmur to the liver.

Lungs

• Pulmonary rales might be present if left ventricular dysfunction is associated with the disease.

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Adolescents (DO NOT EDIT)

Class I

"1. Pulse oximetry at rest and/or during exercise is indicated for the initial evaluation of adolescent and young adult patients with TR if an atrial communication is present, and serially every 1 to 3 years, depending on severity. (Level of Evidence: C)"

Sources

• 2008 ACC/AHA Guidelines incorporated into the 2006 guidelines for the management of patients with valvular heart disease