When is it a problem and when is it not?

By Richard N. Fogoros, MD 

Updated on October 09, 2023

 Medically reviewed by Anthony Pearson, MD

Overview

It quite common for a person having an echocardiogram (a very common heart test often performed in people who are basically healthy), to be told they have tricuspid regurgitation—a “leaky” tricuspid heart valve.

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Many people with tricuspid regurgitation are very surprised to learn that they have a heart valve issue because they feel fine. Their healthcare providers are often as surprised as they are, and may not know what to make of it. Fortunately, it is usually pretty straightforward for your healthcare provider to quickly evaluate this issue, decide whether or not it's a real problem, and if so, how to manage it.

 What Is Pulmonary Regurgitation?

The Tricuspid Valve and Tricuspid Regurgitation

The tricuspid valve separates the right atrium from the right ventricle. Like all heart valves, the purpose of the tricuspid valve is to make sure blood flows through the heart at the right time and in the right direction.

After the right ventricle finishes contraction and begins relaxing, pressures rapidly drop in the right ventricle. Meanwhile, pressures have risen in the right atrium.

When the right atrial pressure exceeds the right ventricular pressure, the tricuspid valve is forced open and blood begins to enter the right ventricle.

The time period when the ventricles relax and fill with blood is called diastole. At the end of diastole, the right atrium contracts pumping more blood into the right ventricle.

When the right ventricle contracts to eject its blood into the pulmonary artery, the tricuspid valve closes to keep blood from leaking back into the right atrium.

• Read about the heart’s chambers and valves.

With tricuspid regurgitation, the tricuspid valve fails to close completely. This allows at least some blood to flow backwards—that is, to regurgitate—into the right atrium as the right ventricle contracts. Some healthcare providers term this tricuspid insufficiency and some term it tricuspid regurgitation (TR).

Risk

For a healthcare provider merely to mention to someone that they have tricuspid regurgitation is not very helpful, because the significance of this valve disorder can vary between none and severe. When tricuspid regurgitation is identified, it is important to determine the severity.

At least some tricuspid regurgitation can be detected in up to 70 percent of normal adults who have echocardiograms.¹ Most normal tricuspid valves have a small or trivial amount of backflow into the right atrium when they close.

With today’s technology, the echocardiogram is often sensitive enough to detect that “normal” whiff of blood—and these individuals, whose valves are essentially normal, are often told they have tricuspid regurgitation, and therefore, a heart valve problem. (As an aside, the same thing happens to some extent with the mitral valve, leading many people to be inappropriately “diagnosed” with mitral valve prolapse or MVP.)

If the healthcare provider tells you that this tricuspid regurgitation is moderate or severe, then you are much more likely to have a significant heart problem that needs to be addressed. In this case, a thorough cardiac evaluation ought to be done to determine the cause and extent of the tricuspid regurgitation.

Causes

Tricuspid regurgitation that is medically significant can have two general kinds of underlying causes. First, the valve itself can become damaged because of some disease process. Second, the valve itself may be normal, but it can become leaky because an underlying cardiac problem has caused the heart to become dilated, so that the tricuspid valve can no longer close normally.

Medical conditions that can damage the tricuspid valve itself include:

• Rheumatic heart disease

• Infectious endocarditis

• Myocardial infarction affecting the right ventricle

• Myxomatous degeneration of the valve (similar to MVP)

• Injury from a pacemaker or implantable defibrillator lead²

• Marfan syndrome

• Carcinoid syndrome

• Congenital heart disease

The most common cause of tricuspid regurgitation, by far, is a “functional’ disturbance of the tricuspid valve, where the valve itself is essentially normal — but leakage occurs because a heart disorder of some kind distorts the heart. This most commonly happens because the right atrium or the right ventricle become dilated in a way that prevents the tricuspid valve from closing completely.

Heart problems that commonly cause functional tricuspid regurgitation include:

• Pulmonary artery hypertension

• Heart failure

• Mitral stenosis or mitral regurgitation

• Pulmonary embolism

• Hyperthyroidism

Most people with significant tricuspid regurgitation will turn out to have a functional valve disorder produced by one of these conditions. A full cardiac evaluation will be required to identify the nature and severity of the underlying problem, and to determine the best way of treating it.

 Aortic Regurgitation (Leaky Heart Valve): What to Know

Symptoms

The large majority of people with tricuspid regurgitation have no symptoms that can be attributed to the valve disorder itself. Any symptoms, if present, are usually caused by the underlying condition that is producing a functional valve problem.

However, if the tricuspid regurgitation is severe, it may directly produce symptoms. These symptoms may include an uncomfortable feeling of an unusual pulsation in the neck, or abdominal pain and edema (swelling). If right-sided heart failure develops, pronounced dyspnea (shortness of breath), weakness and dizziness may occur. But even with severe tricuspid regurgitation, symptoms are usually caused more by the underlying cardiac disorder than by the regurgitation itself.

Diagnosis

Tricuspid regurgitation is diagnosed with an echocardiogram. The two key questions after tricuspid regurgitation is diagnosed ought to be:

1. What is the underlying cause?

2. How severe is it?

Both of these questions are important in deciding how—and even whether—to treat the valve problem.

In most cases, these two questions are answered quite readily when the healthcare provider performs a careful medical history and physical examination, and obtains a high-quality echocardiogram. At that point, a management plan can be developed.³

Takeaway:

While most people with tricuspid regurgitation have a very mild condition that requires no treatment, sometimes it can be a serious matter. So if you are told you have tricuspid regurgitation, the first order of business is for your healthcare provider to determine the underlying cause and the severity of the condition. 

Management

The most important step in managing tricuspid regurgitation is to identify and treat the underlying cause. This is especially important with functional tricuspid regurgitation, where the tricuspid valve itself is fundamentally normal.⁴

Functional tricuspid regurgitation is most often caused by pulmonary artery hypertension. Treating pulmonary hypertension can substantially improve the tricuspid regurgitation. So, reversible causes of pulmonary hypertension—especially heart failure, mitral valve disease, or pulmonary embolus—ought to be aggressively treated.

If the tricuspid regurgitation is not functional—that is, it is caused by an intrinsic problem with the tricuspid valve itself—management usually depends on the severity of the regurgitation and any associated symptoms.

People who have only very mild tricuspid regurgitation without any other cardiac problems usually have tricuspid valves that are fundamentally normal, and, except for periodic follow-up examinations, need no “management” at all.

Even if intrinsic tricuspid regurgitation is moderate or severe, as long as there are no symptoms and the echocardiogram shows normal cardiac function and normal heart pressures, there should be no limitation placed on their physical activity. The only real “management” is periodic re-evaluations with a cardiologist.

Treatment

There are a few situations in which valve surgery ought to be considered in people who have tricuspid regurgitation.

Surgery should become an option if the tricuspid regurgitation itself is judged to be causing significant symptoms.

Tricuspid valve surgery is also recommended for people who have severe tricuspid regurgitation and are having surgery to repair or replace a diseased mitral valve. In this situation both valves are dealt with during one operation. This, by far, is the most common reason for performing tricuspid valve surgery.

In general when surgery is needed, whenever it is feasible repair of the tricuspid valve is preferred over valve replacement. Cardiologists have developed methods to repair tricuspid valves without the need for open heart surgery. These tricuspid clips are implanted by threading a tube into the leg veins and up into the right ventricle.⁵

Summary

If you are told you have tricuspid regurgitation, the key is for your healthcare provider to determine the underlying cause and the severity of the problem. Fortunately, this is usually not a difficult or time-consuming process.

The majority of people diagnosed with tricuspid regurgitation will turn out to have a mild form of the disorder, or no real problem at all. Of those whose tricuspid regurgitation turns out to be a significant issue, most will have a functional valve problem caused by another cardiovascular disorder—and their treatment will require aggressively managing that underlying problem. Surgery for tricuspid regurgitation is not commonly required.