Should a 64-year-old female patient with mild pulmonic regurgitation and mild tricuspid regurgitation, and a normal ejection fraction, be referred to cardiology?

Should This Patient Be Referred to Cardiology?

No, cardiology referral is not indicated for this 64-year-old female patient with mild pulmonic regurgitation, mild tricuspid regurgitation, and normal ejection fraction, as mild valvular regurgitation is a benign finding that does not require specialist evaluation or intervention.

Rationale for No Referral

Mild Pulmonic Regurgitation is Benign

• Mild pulmonary regurgitation may be a normal finding on Doppler echocardiography and does not require intervention or specialist follow-up 1
• Among patients with pulmonary regurgitation, right ventricular systolic dysfunction was uncommon, being present in only 9% of cases, and most patients continued to do well long-term 1
• The ACC/AHA guidelines explicitly state that mild pulmonary regurgitation is frequently detected by echocardiography and is generally of no clinical significance 1

Mild Tricuspid Regurgitation Does Not Warrant Intervention

• The American Heart Association confirms that mild tricuspid regurgitation with normal valves and normal ejection fraction does not cause hemodynamically significant volume overload and does not meet criteria for surgical intervention 2
• The ACC/AHA recommends against pursuing surgical intervention for mild TR, as this degree of regurgitation does not warrant valve repair or replacement 2
• Echocardiographic grading should use qualitative descriptors (none/trace, mild, moderate, moderate-severe, severe) for both tricuspid and pulmonic regurgitation 1

Normal Ejection Fraction Indicates Preserved Ventricular Function

• The presence of normal left ventricular ejection fraction (>50%) indicates no ventricular dysfunction has occurred from these mild valvular lesions 1
• Right ventricular size and function should be assessed, but in the absence of RV dilation or dysfunction, mild regurgitation requires no intervention 1

Appropriate Management Strategy

Primary Care Monitoring is Sufficient

• Continue routine primary care follow-up without cardiology referral, as these mild valvular findings do not alter management or prognosis 1
• Document the findings for longitudinal tracking, but no specific cardiac monitoring beyond standard care is needed 2

When to Consider Future Referral

• Refer only if the patient develops:
  • Symptoms of dyspnea, exercise intolerance, or signs of right heart failure 1
  • Progression to moderate or severe regurgitation on future echocardiograms 1
  • Right ventricular dilation or dysfunction (RV end-diastolic area >28 cm², fractional area change <32%) 1
  • Evidence of pulmonary hypertension (estimated pulmonary artery systolic pressure >50 mmHg) 1, 3

Critical Pitfall to Avoid

• Do not over-attribute non-specific symptoms to mild valvular regurgitation, as these mild findings are frequently incidental and do not cause symptoms 2
• The American Heart Association advises against attributing clinical findings to mild TR when other more likely etiologies exist 2
• Avoid unnecessary serial echocardiograms for stable mild regurgitation, as progression is uncommon and does not require surveillance imaging 1

Prognostic Context

• Moderate-to-severe TR is independently associated with increased mortality (HR 1.17-1.57 depending on severity), but mild TR does not carry this excess risk 4, 5
• The adverse outcomes associated with tricuspid regurgitation occur primarily with moderate or greater severity, particularly when accompanied by pulmonary hypertension or reduced ejection fraction 6, 3, 7
• In patients with preserved ejection fraction and only mild regurgitation, long-term prognosis is excellent without intervention 1