What is the diagnosis for a patient with a normal tricuspid valve (TV) structure, trivial tricuspid regurgitation (TR), and no stenosis, as well as a normal pulmonic valve (PV) structure with no stenosis or regurgitation?

From the Guidelines

The patient's echocardiogram findings indicate normal tricuspid and pulmonic valves with no significant abnormalities, and therefore, no intervention is required based on these findings, and routine cardiac follow-up is appropriate. The tricuspid valve has trivial regurgitation, which is a common and benign finding in healthy individuals, as noted in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1. There is no evidence of tricuspid stenosis. The inferior vena cava (IVC) diameter is 1.3 cm, which is within normal limits, suggesting normal right atrial pressure, confirmed by the measured right atrial pressure of 3 mmHg (normal range is 1-7 mmHg). Some key points to consider in the management of tricuspid regurgitation include:

• The use of transthoracic echocardiography (TTE) as the key diagnostic imaging modality, as recommended by the American College of Cardiology/American Heart Association (ACC/AHA) 1 and the European Society of Cardiology (ESC) 1.
• The consideration of additional tests, such as right-heart catheterization, when clinical and non-invasive data are discordant or inadequate, as recommended by the ACC/AHA 1 and the Japanese Circulation Society (JCS) Joint Working Group 1.
• The definition of severe tricuspid regurgitation, which includes criteria such as central jet ≥50% RA, dense CW Doppler signal with triangular shape, and vena contracta ≥7 mm, as recommended by the ACC/AHA 1 and the ESC 1. The tricuspid regurgitation velocity is 1.2 m/s, which is not elevated and indicates normal right ventricular systolic pressure. The pulmonic valve also appears structurally normal with no stenosis or regurgitation. The peak velocity across the pulmonic valve is 1.0 m/s with a peak gradient of 4 mmHg and mean gradient of 2 mmHg, all within normal parameters. According to the most recent and highest quality study, the 2022 systematic review of clinical practice guidelines and recommendations for tricuspid regurgitation management 1, these findings suggest normal right heart hemodynamics with no evidence of pulmonary hypertension or right-sided valvular disease. Key recommendations for the management of tricuspid regurgitation include:
• Screening for tricuspid regurgitation using TTE, as recommended by the ACC/AHA 1 and the ESC 1.
• Additional tests, such as right-heart catheterization, when clinical and non-invasive data are discordant or inadequate, as recommended by the ACC/AHA 1 and the JCS Joint Working Group 1.
• Definition of severe tricuspid regurgitation, which includes criteria such as central jet ≥50% RA, dense CW Doppler signal with triangular shape, and vena contracta ≥7 mm, as recommended by the ACC/AHA 1 and the ESC 1.

From the Research

Tricuspid Valve Assessment

• The tricuspid valve structure is reported as normal with trivial regurgitation and a TR velocity of 1.2 m/s 2, 3.
• The TR gradient is >50%, indicating potential tricuspid regurgitation, but the provided velocity and gradient values do not exceed the normal range 4.
• The IVC calibre is 1.3 cm, and the RVSP is not explicitly stated, but the RA pressure is 3mmHg, which is within normal limits.

Pulmonic Valve Evaluation

• The pulmonic valve structure is normal with no stenosis or regurgitation 2, 3.
• The peak velocity is 1.0 m/s, and the peak gradient is 4 mmHg, which are within normal ranges 4.
• The mean velocity and mean gradient are 0.8 m/s and 2 mmHg, respectively, also indicating no significant pulmonic valve disease.

Clinical Implications

• Tricuspid regurgitation can be classified into primary and secondary types, with secondary TR being more common and often caused by tricuspid annular dilatation, right heart failure, and/or pulmonary hypertension 3.
• Echocardiography is essential for assessing TR severity and mechanisms, as well as estimating pulmonary pressure and characterizing LV disease 2, 3.
• The management of TR includes medical treatment with diuretics, ACE inhibitors, and aldosterone antagonists, as well as surgical or transcatheter interventions in selected cases 2, 3.