What are the physical exam findings of tricuspid regurgitation?

Physical Examination Findings of Tricuspid Regurgitation

The most characteristic physical examination findings of tricuspid regurgitation include elevated "c-V" waves in the jugular venous pulse, a systolic murmur at the lower sternal border that increases with inspiration, and a pulsatile liver edge. 1

Jugular Venous Examination

• Elevated "c-V" waves: Most specific finding, often the only clue to severe TR even when murmur is inaudible 1
• Prominent V waves: Visible as distention during systole
• Prominent Y descent: Rapid collapse following the V wave
• Kussmaul's sign: Paradoxical increase in jugular venous pressure during inspiration (suggests elevated right atrial pressure) 1

Cardiac Auscultation

• Holosystolic murmur: Best heard at the lower left sternal border
• Respiratory variation: Characteristic increase in murmur intensity during inspiration (Carvallo's sign)
• Loud first heart sound (S1): May be present, especially in primary TR 1
• Systolic clicks: May be present in some cases 1

Abdominal Examination

• Pulsatile liver: Palpable systolic pulsations of the liver edge
• Hepatomegaly: Due to passive congestion in advanced cases
• Ascites: In severe, long-standing TR with right heart failure

Other Findings

• Peripheral edema: Bilateral lower extremity edema in advanced cases
• Low cardiac output signs: Fatigue, cool extremities, peripheral cyanosis 1
• Central cyanosis: May be present if TR is associated with right-to-left shunting (e.g., through PFO/ASD) 1

Severity Assessment

The physical examination can provide clues to TR severity:

Mild TR

• Soft systolic murmur
• Normal jugular venous pulse
• No hepatomegaly or peripheral edema

Moderate TR

• More prominent systolic murmur
• Visible jugular venous distention
• Mild hepatomegaly

Severe TR

• Prominent systolic murmur (though may be soft in massive TR)
• Prominent "c-V" waves in jugular venous pulse
• Systolic hepatic pulsations
• Hepatomegaly, ascites, peripheral edema
• Signs of right heart failure 1

Special Scenarios

• Ebstein's anomaly: May present with all the above findings plus cyanosis and a QR pattern in right precordial leads on ECG 1
• Massive TR: Paradoxically may have a softer murmur due to equalization of right atrial and right ventricular pressures 1
• Acute severe TR: May present with right heart failure symptoms despite normal right ventricular size 1

Clinical Pitfalls

• TR murmur may be inaudible even in severe cases, making jugular venous examination crucial
• Atrial fibrillation can mask typical jugular venous wave patterns
• Hepatic pulsation must be distinguished from transmission of abdominal aortic pulsations
• Right heart failure signs may be attributed to left heart failure, missing the TR diagnosis

Remember that while physical examination is valuable, echocardiography remains the gold standard for confirming the diagnosis and assessing severity of tricuspid regurgitation.