Heart valve disease module 3: disease presentation

Right-sided valve disease

Clinically significant, right-sided isolated native valve disease is much less common than left-sided disease. It constituted just 1.2% of cases in the Euro Heart Survey,⁸⁰ and is much less well studied than left-sided valve disease. Minor right-sided regurgitation is a common finding on echocardiography, and within normal limits.

Tricuspid stenosis

Tricuspid stenosis (TS) is rare in industrially-developed countries, as 90% results from rheumatic disease. TS progresses slowly and it frequently co-exists with left-sided rheumatic valve disease which may cause symptoms earlier. TS causes dyspnoea, fatigue and peripheral oedema.^81–83

The murmur of TS is a mid-diastolic murmur louder on inspiration and lying down, with a pre-systolic component in sinus rhythm.⁸⁴ A giant ‘a wave’ may be seen in the jugular venous pulse (JVP).

Tricuspid regurgitation

True primary tricuspid regurgitation (TR) (see figure 12) is extremely rare, and the natural history is therefore largely unknown. The majority of clinically significant TR is secondary to other pathology, most commonly as a result of RV dilatation, and the natural history of the TR is therefore dictated by the primary cause. Clinically undetectable TR can be found on echocardiography in most patients and is within normal limits; in contrast, severe TR has a poor prognosis.

When TR is secondary to RV dilatation or left-sided valve lesions, treatment of the underlying cause may not result in improvement in TR severity; factors predictive of this include RV dysfunction, tricuspid annular dilatation, and pulmonary hypertension.

Symptoms of TR develop when the RV becomes unable to cope with the increased stroke volume. Typical symptoms are:

• exertional dyspnoea, which may become dyspnoea at rest
• peripheral oedema
• fatigue
• abdominal distension
• prominent venous pulsation
• a sensation of increased pulsation in the head and neck.

The murmur of TR is classically pan-systolic, heard along the left sternal edge, radiating to the hepatic area, and is louder on inspiration. However, it may only be heard in 20% of patients with confirmed TR.^85–87 Jugular venous distension (see figure 13), with prominent ‘CV’ waves, is commonly seen in severe disease, and venous distension may increase with inspiration. A pulsatile liver is less common than hepatomegaly alone, and a right ventricular heave may also be present. Other signs of right ventricular dysfunction may also be prominent.