Insufficiency of the tricuspid (IT)

notes by dr Claudio Italiano

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Endocarditis, therapy and prophylaxis
Mitral insufficiency
fficienza mitralica

La stenosi aortica
 

Definition

It means that the valve is insufficient, ie at the time of systole or contraction of the right ventricle, since the valve is located between right atrium and right ventricle (see anatomy of the heart), blood, rather than proceeding to the pulmonary artery, partly regurgitation through the insufficient valve (so to speak incontinent and flattened) and returns to the overlying atrium, with consequent stasis of the venous systemic circulation and possibility, in the most severe cases, of liver and liver stasis "nutmeg", known as condition of "cardiac cirrhosis" or of stasis liver ". Since the venous system of the head is also discharged through the jugular, in the succlavias and in the upper cavity and in the right heart, the impeded discharge pressure is manifested by the jugular turgidity. The most common cause of IT is functional, related to dilatation of the right ventricle, resulting in a flattening of the tricuspid annulus. This is due to multiple possible causes: mitral valvulopathy, congenital heart disease, right ventricular infarction, pulmonary hypertension and pulmonary heart. Among the possible organic primitive causes of IT we remember those congenital: Ebstein anomaly, partial ventricular atrium channel, mitral prolapse; and those acquired: rheumatic vice, infarction with papillary muscle injury, trauma, infective endocarditis, carcinoid syndrome.

Symptomatology

It's generally well tolerated in the absence of pulmonary hypertension. When this occurs, the cardiac output decreases and the clinical manifestations typical of the right ventricular failure appear, with an increasing trend. Therefore these patients have marked hepatomegaly, peripheral edema and considerably dilated jugular veins (see photo). On examination, the jugular veins are dilated and there is a prominent V wave followed by an accentuated collapse. In the left parasternal the right ventricular impulse, hyperdynamic and sometimes along the lower right margin of the sternum, a systolic pulse produced by the enlarged right atrium can be perceived.

Objective examination

Turgore delle giugulariListening to it, a holosystolic murmur is more easily audible at the fourth intercostal space in the left parasternal or in the subxifoidal area. When the right ventricle is greatly enlarged and occupies the anterior surface of the heart, the breath is better audible to the tip and can easily be confused with a finding from mitral insufficiency. The puff of IT increases during inspiration (Carvallo maneuver); but when, due to the right ventricular failure, the increase in the right ventricular filling can not further increase the systolic throw, the inspiratory accentuation of the breath is not evident. In these cases the erected station with consequent reduction of venous return, can again bring out the variation of the breath with the breath acts. In addition, the breath increases in intensity with the Muller maneuver (forced inhalation to closed glottis) with exercise and with inhalation of amyl nitrite. It is reduced instead of intensity and duration in an upright position. Frequent is the finding of a third tone originating from the right ventricle which is accentuated with inspiration. Increased atrioventricular flow may cause audible protodiastolic murmur to the tricuspid focus.
On radiological examination, a marked cardiomegaly due to dilatation of the ventricle and of the right atrium is evident in anterior anesthesia, with enlargement at the expense of the right and left transverse hemidiameter, with the tip at the top. The role of angiography in the diagnosis and quantification of LT is somewhat controversial. In fact the contrast medium injected by catheter, in right ventricle can create false positives since the regurgitation of this medium in the left atrium could be linked to the fact that the catheter passing through the valve prevents its perfect closure. At echocardiography, we can highlight the enlargement of the right ventricle with increased Chinese and paradoxical movement of the interventricular septum linked to the volume overload. In patients with IT secondary to right ventricular dilatation and pulmonary hypertension the pulmonary valve presents reduction or absence of the "a" wave. A possible prolapse of the tricuspid can easily be diagnosed with the echocardiographic examination and shows characteristics quite similar to those of mitral prolapse.
The rapid injection of 10-20 cc of saline into a peripheral vein causes the small two-dimensional echo to show small bubbles that in the case of IT present a movement of the air coming through the tricuspid valve. IT in the absence of pulmonary hypertension does not require surgical treatment, while in the case of pulmonary hypertension there is considerable benefit from the surgical intervention with the Carpentier ring implant. In patients with IT associated with mitral valvulopathy and pulmonary hypertension, behavior is different depending on the degree of tricuspid regurgitation assessed by palpating the valve during surgery. In cases of mild IT, no surgical treatment should be performed. In the case of medium-sized IT, good results are obtained with the anuloplasty according to De Vega or with the Carpentier ring. Less clear is the line of conduct to be taken in case of severe IT: some surgeons perform the anuloplasty, others the valve replacement. Organic IT, due to rheumatic disease or endocarditis, in most cases requires valve replacement. In these cases, due to the high incidence of thrombotic events related to the mechanical prosthesis in this area (low pressure and flow velocity), it is preferable to implant porcine biological prostheses.

 

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