Tricuspid Insufficiency (TI)

What is it?

Tricuspid insufficiency (or tricuspid regurgitation) is a pathological condition in which the tricuspid valve, located between the right atrium and the right ventricle of the heart does not close completely, allowing a reflux of blood from the ventricle to the right atrium of the heart, during the contraction phase of the heart (systole).
This causes an increase of pressures in the venous district with consequent onset of breathlessness, declivous edema (swelling of the lower limbs) and, in advanced cases, ascites and pleural effusion. 

Causes and risk factors

Primary tricuspid insufficiency is quite rare. It is a consequence of intrinsic valve problems caused by congenital diseases, infective endocarditis, rheumatic fever, thoracic trauma, thoracic radiotherapy, and valve lesions from invasive diagnostic and therapeutic procedures. The majority of cases found in adulthood are secondary or functional tricuspid insufficiency, i.e. a consequence of other valvular or cardiac muscle pathologies due to heart failure, myocardial infarction, pulmonary hypertension, left ventricular hypertrophy, with repercussions on the pulmonary circulation and on the right ventricle (mitral and aortic valvulopathy). Tricuspid insufficiency may be responsible for heart failure and atrial fibrillation.

Which are the symptoms?

In its early stages, Tricuspid valve insufficiency is usually asymptomatic. Symptoms of severe tricuspid insufficiency include fatigue, dyspnea, abdominal bloating, liver enlargement, digestive difficulties, appearance of lower extremity edema, and acute heart failure.

  • fatigue
  • dyspnea
  • abdominal bloating
  • liver enlargement
  • digestive difficulties
  • edema in lower limbs    

How is it diagnosed?

Tricuspid insufficiency is diagnosed with a colordoppler echocardiogram. 

Suggested exams

How is it treated?

Treatment of tricuspid insufficiency depends on the severity of regurgitation, presence of symptoms, worsening of the general clinical picture, and cause of the disease.
When the failure is isolated and mild to moderate in degree, the disease may progress slowly and without causing problems. It is usually diagnosed incidentally with an ultrasound performed for other conditions. At this stage, adherence to a healthy lifestyle and periodic clinical follow-up are recommended.
Patients with severe tricuspid insufficiency (or severe tricuspid regurgitation) should undergo surgery as soon as symptoms appear despite medical treatment, or when there is moderate and progressive enlargement or dysfunction of the right ventricle. 

Surgery can be:
Repair, where the native valve is retained, and where different repair techniques can be used individually or in combination to reconstruct the valve and make it continent;
Anuloplasty, where the annulus of the tricuspid valve is reinforced with a prosthetic ring which narrows and blocks future dilation of the annulus;
Reduction of the circumferential dimensions of the annulus itself. This technique is indicated if tricuspid insufficiency is secondary to dilatation of the annulus.
Valve flap repair or reconstruction, with preservation of the native valve.
​Replacement of the tricuspid valve with a biological prosthesis, in the event that repair is not possible or does not guarantee an optimal and lasting result. Biologic prostheses do not require anticoagulation therapy, and when used in the right heart, as opposed to the left, have a life span of more than 10 years.

Whenever possible, it is preferable to repair a valve rather than replace it because repair is associated with better maintenance of cardiac function, better survival, and lower risk of endocarditis.
Minimally invasive surgery also plays an important role in tricuspid insufficiency, and is performed both in the treatment of isolated insufficiency and in association with mitral valve surgery.  The minimally invasive approach has demonstrated better clinical outcomes, especially on reduction of postoperative bleeding, reduction of ICU and overall hospital stay, and therefore faster recovery times after surgery in general.
Non-surgical percutaneous approach:
In cases of degeneration of a previously implanted biological prosthesis, if the patient is advanced in age, with other pathologies and/or contraindications to a classic surgery, and the surgical risk is too high, the implantation of the prosthesis can be carried out percutaneously through a catheter, which is made to go up from the femoral vein to the heart, placing a new prosthesis inside the existing one (Valve-in-Valve). Considering the often non-negligible surgical risk of traditional cardiac surgery to repair or replace the tricuspid valve (due to the frequent coexistence of liver and/or kidney failure), new transcatheter procedures for the treatment of tricuspid valvulopathy are being studied and developed. 
All possible options and aspects related to each individual patient, however, are discussed and deepened with the cardiac surgeon before the operation.

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