What are the symptoms of wide open tricuspid regurgitation?

Symptoms of Wide Open Tricuspid Regurgitation

Patients with severe tricuspid regurgitation (TR) commonly present with fatigue from low cardiac output, abdominal fullness, edema, and palpitations (particularly if atrial fibrillation is present). 1

Cardinal Symptoms and Signs

• Fatigue and reduced exercise capacity due to decreased cardiac output, which is often the earliest symptom 1
• Abdominal bloating and fullness resulting from hepatic congestion and ascites 1
• Peripheral edema (often bilateral lower extremity) due to elevated systemic venous pressure 1
• Palpitations - particularly in patients with concomitant atrial fibrillation, which occurs in approximately 70-88% of patients with severe TR 1, 2
• Anorexia in advanced cases due to splanchnic congestion 1
• Dyspnea - both with exertion and at rest in advanced cases 1, 3

Physical Examination Findings

• Elevated jugular venous pressure with prominent "c-V" waves, which may be the only clue to severe TR in some patients 1
• Systolic murmur at the lower sternal border that increases with inspiration (Carvallo's sign), although this may be absent even in severe TR 1
• Pulsatile liver edge due to systolic hepatic congestion 1
• Positive hepatojugular reflux - a sustained increase in jugular venous pressure when pressure is applied to the abdomen, indicating right-sided volume overload 4
• Peripheral edema - often significant and may extend to the thighs and abdominal wall in severe cases 1, 3
• Ascites in advanced cases 1, 2

Advanced Manifestations

• Progressive hepatic dysfunction due to chronic elevated right atrial pressure, which can lead to abnormal liver function tests 1
• Reduced respiratory variation of inferior vena cava diameter on echocardiography, which is an independent marker of volume overload in severe TR 2
• Right heart failure symptoms including increased fatigue, worsening edema, and orthopnea 3, 5
• Prolonged hospitalizations and frequent rehospitalizations - 25% of patients with severe TR require admission for heart failure, and 36.8% of those with right heart failure require rehospitalization 3

Complications and Long-term Consequences

• Heart failure - the most common cause of death (50%) in patients with severe TR 3
• Atrial fibrillation - present in up to 70.5% of patients with severe TR 3
• Reduced survival - mean survival from diagnosis of severe TR is approximately 4.35 years 3
• Decreased quality of life due to persistent symptoms and functional limitations 3, 5

Diagnostic Considerations

• Symptoms may be subtle or absent in early stages, leading to delayed diagnosis 1, 6
• Symptoms often worsen progressively as right ventricular dysfunction develops 1, 5
• The presence of symptoms, particularly right heart failure, places patients in Stage D of TR severity classification 1
• Symptoms may be masked or complicated by coexisting left-sided heart disease 6, 5

Clinical Pitfalls

• A murmur may be inaudible even with severe TR, making jugular venous findings crucial for diagnosis 1
• Symptoms may be attributed incorrectly to other conditions, delaying appropriate treatment 6, 5
• Waiting for symptoms to develop before considering intervention may result in irreversible right ventricular dysfunction 3, 5
• Isolated TR is often undertreated despite its significant impact on morbidity and mortality 7, 5