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Tricuspid valve regurgitation

Overview

Tricuspid valve regurgitation is a condition in which the valve between the two right heart chambers (right ventricle and right atrium) doesn't close properly. This situation results in blood flowing back into your heart's upper right chamber (right atrium).

Tricuspid valve regurgitation can be the result of a condition you're born with (congenital heart disease), or it can occur due to valve abnormalities caused by other conditions.

If your condition is mild, you may not need treatment, and your condition may be monitored. However, if you have severe tricuspid valve regurgitation and you're experiencing signs and symptoms, treatment may be necessary.

Symptoms

Tricuspid valve regurgitation often doesn't cause signs or symptoms until the condition is severe. You may be diagnosed with this condition when having tests for other conditions.

Signs and symptoms of tricuspid valve regurgitation may include:

  • Fatigue
  • Declining exercise capacity
  • Swelling in your abdomen, legs or veins in your neck
  • Abnormal heart rhythms
  • Pulsing in your neck
  • An enlarged liver
  • Shortness of breath with activity

You may also experience signs or symptoms of the condition that is causing tricuspid valve regurgitation, such as pulmonary hypertension. Pulmonary hypertension symptoms may include fatigue, weakness, difficulty exercising and shortness of breath.

When to see a doctor

Severe tricuspid valve regurgitation can result in heart failure. If you have signs or symptoms of heart failure — such as feeling easily fatigued or short of breath, even with normal activity — see your doctor. Your doctor may refer you to a doctor trained in heart conditions (cardiologist).

Causes

Tricuspid valve regurgitation can have several causes.

Tricuspid valve regurgitation is usually caused by the lower right heart chamber (right ventricle) bulging (dilating), which can lead to the tricuspid valve not working properly. This can be due to several conditions that affect the right ventricle, such as heart failure, conditions that cause high blood pressure in the arteries in your lungs (pulmonary hypertension) or an abnormal heart muscle condition (cardiomyopathy). Tricuspid valve regurgitation often occurs with heart conditions that affect the left side of the heart.

Tricuspid valve regurgitation can also be caused by valve problems due to:

  • Ebstein's anomaly. In this condition, the malformed tricuspid valve sits lower than normal in the right ventricle, and the tricuspid valve's leaflets are abnormally formed. This can lead to blood leaking backward (regurgitating) into the right atrium. Tricuspid valve regurgitation in children is usually caused by heart disease present at birth (congenital heart disease), and Ebstein's anomaly is the most common congenital heart disease that causes the condition. Often it may be overlooked and not diagnosed until adulthood.
  • Infective endocarditis. The tricuspid valve may be damaged by an infection of the lining of the heart (infective endocarditis) that can involve heart valves.
  • Carcinoid syndrome. In this rare condition, tumors usually develop in your digestive system or lungs and can spread to your liver or lymph nodes. Carcinoid syndrome can cause carcinoid heart disease, a condition in which substances produced by the tumors result in scarring of the heart valves. This condition often affects the function of the tricuspid valve and pulmonary valve.
  • Implantable device wires (leads). Pacemaker or implantable cardioverter-defibrillator wires can sometimes cause injury to the tricuspid valve during placement or removal of the implantable device.
  • Endomyocardial biopsy. In an endomyocardial biopsy, a small amount of heart muscle tissue is removed and tested for signs of inflammation or infection. Valve damage can sometimes occur during this procedure.
  • Blunt chest trauma. Experiencing trauma to your chest, such as in a car accident, can lead to tricuspid valve regurgitation.
  • Rheumatic fever. Rheumatic fever — a complication of untreated strep throat and once a common childhood illness in the United States — can damage the tricuspid valve, leading to tricuspid valve regurgitation later in life. Rheumatic fever can also damage more than one heart valve, and in more than one way. Rheumatic fever is rare in the United States, but still common in some countries.
  • Congenital heart defects. Some heart defects present at birth (congenital or genetic) may affect the tricuspid valve. Most commonly this is Ebstein's anomaly.
  • Marfan syndrome. Marfan syndrome, a connective tissue disorder present at birth (congenital), can cause tricuspid valve regurgitation.
  • Medications. If you've taken certain medications such as fenfluramine (no longer sold on the market), ergot alkaloid medications such as ergotamine (Cafergot, Migergot), and some medications used for restless legs syndrome and Parkinson's disease, such as pergolide (no longer sold in the United States) or cabergoline, you may have an increased risk of tricuspid valve regurgitation.
  • Radiation. Chest radiation may damage the tricuspid valve and cause tricuspid valve regurgitation.

How the heart works

Your heart, the center of your circulatory system, is made up of four chambers. The two upper chambers (atria) receive blood. The two lower chambers (ventricles) pump blood.

Four heart valves open and close to let blood flow in one direction through your heart. The tricuspid valve — which lies between the two chambers on the right side of your heart — consists of three flaps of tissue called leaflets.

The tricuspid valve opens when blood flows from the right atrium to the right ventricle. Then the flaps close to prevent the blood that has just passed into the right ventricle from flowing backward.

In tricuspid valve regurgitation, the tricuspid valve doesn't close tightly. This causes the blood to flow back into the right atrium during each heartbeat.

Ebstein's anomaly

Ebstein's anomaly is a rare heart defect in which the tricuspid valve — the valve between the upper right chamber (right atrium) and the lower right chamber (right ventricle) of the heart — isn't formed properly. As a result, blood leaks back through the valve and into the right atrium. Atrial septal defect, the most common defect associated with Ebstein's anomaly, is a hole between the two upper chambers of the heart. A normal heart is shown on the left.

Risk factors

Several factors can increase your risk of tricuspid valve regurgitation, including:

  • Infections such as infective endocarditis or rheumatic fever. These infections can cause damage to the tricuspid valve.
  • A heart attack. A heart attack can damage your heart and affect the right ventricle and function of the tricuspid valve.
  • Heart failure. Heart failure can increase your risk of developing tricuspid valve regurgitation.
  • Pulmonary hypertension. High blood pressure in the arteries in your lungs (pulmonary hypertension) can increase your risk of tricuspid valve regurgitation.
  • Heart disease. Several forms of heart disease and heart valve disease may increase your risk of developing tricuspid valve regurgitation.
  • Congenital heart disease. You may be born with a condition or heart defect that affects your tricuspid valve. Ebstein's anomaly is the most common congenital heart disease.
  • Use of certain medications. If you've used medications such as fenfluramine (no longer sold on the market), ergot alkaloid medications such as ergotamine (Cafergot, Migergot), and some medications used for restless legs syndrome and Parkinson's disease, such as pergolide (no longer sold in the United States) or cabergoline, you may have an increased risk of tricuspid valve regurgitation.
  • Radiation. Chest radiation may damage the tricuspid valve and cause tricuspid valve regurgitation.

Complications

If tricuspid valve regurgitation lasts, it can lead to:

  • Heart failure. In severe tricuspid valve regurgitation, pressure can rise in your right ventricle due to blood flowing backward into the right atrium and less blood flowing forward through the right ventricle and into the lungs. Your right ventricle can expand and weaken over time, leading to heart failure.
  • Atrial fibrillation. Some people with severe tricuspid valve regurgitation also may have a common heart rhythm disorder called atrial fibrillation.

Diagnosis

Tricuspid valve regurgitation often has no symptoms. When symptoms are present, they can range from fatigue and decreased exercise tolerance to swelling in the lower extremities and abdomen. You may be diagnosed when having tests for other conditions.

To diagnose your condition, your doctor may review your medical history and conduct a physical examination.

Tests

Your doctor may order several tests to diagnose tricuspid valve regurgitation, determine the severity and cause of your condition, and develop an appropriate treatment plan. Tests may include:

Echocardiogram

This is the test most commonly used to diagnose tricuspid valve regurgitation. In this test, sound waves produce detailed images of your heart. This test assesses the structure of your heart, the tricuspid valve and the blood flow through your heart. Your doctor also may order a 3-D echocardiogram.

Your doctor may also order a transesophageal echocardiogram. In this test, your doctor inserts a tube with a tiny sound device (transducer) into the part of your digestive tract that runs from your throat to your stomach (esophagus). Because the esophagus lies close to your heart, the transducer provides a detailed image of your heart.

Cardiac MRI

A cardiac MRI uses magnetic fields and radio waves to create detailed images of your heart. This test may be used to determine the severity of your condition and assess the size and function of your lower right heart chamber (right ventricle).

Electrocardiogram (ECG)

In this test, sensor patches with wires attached (electrodes) measure the electrical impulses given off by your heart. An ECG can detect enlarged chambers of your heart, heart disease and abnormal heart rhythms.

Chest X-ray

In a chest X-ray, your doctor studies the size and shape of your heart and evaluates your lungs.

Electrophysiology tests

Your doctor may conduct electrophysiology tests if you have an abnormal heart rhythm. In an electrophysiology test, a doctor inserts long, thin tubes (catheters) with sensors (electrodes) at the tips into an artery in your groin and threads them to your heart using X-ray imaging. The electrodes can precisely map the spread of electrical impulses through your heart.

Exercise tests or stress tests

Different exercise tests help measure your activity tolerance and monitor your heart's response to physical exertion. If you are unable to exercise, medications to mimic the effect of exercise on your heart may be used.

Cardiac catheterization

Doctors rarely use this test to diagnose tricuspid valve regurgitation. However, in some cases doctors may order it to evaluate your lung (pulmonary) pressure and to determine other causes of tricuspid valve regurgitation.

In this procedure, doctors insert a long, thin tube (catheter) into a blood vessel in your groin, arm or neck and guide it to your heart using X-ray imaging. A special dye injected through the catheter helps your doctor see the blood flow through your heart, blood vessels and valves, and allows your doctor to check for abnormalities inside the heart and lungs.

Treatment

Treatment for tricuspid valve regurgitation depends on the severity of your condition, your signs and symptoms, and the underlying cause of your condition. The goal of treatment is to reduce your symptoms, avoid future complications and live longer.

If an underlying condition such as heart failure or endocarditis is causing your tricuspid valve regurgitation, doctors will treat those conditions. If you have pulmonary hypertension, treating its cause, such as heart failure or mitral valve disease, may help improve tricuspid regurgitation.

If your condition is due to a heart condition present at birth (congenital heart disease), such as Ebstein's anomaly, you will be treated by doctors trained in congenital heart disease.

Your treatment may include:

Regular monitoring

If you have mild tricuspid valve regurgitation, you may only need to have regular follow-up appointments with your doctor to monitor your condition.

Medications

Your doctor may prescribe medications to treat other conditions. Your doctor may prescribe medications for signs and symptoms of heart failure, if you need them. These may include drugs that prevent water retention (diuretics) and other medications.

If you have heart rhythm disorders (arrhythmias), your doctor may prescribe medications to help control the heart rate and maintain a normal heart rhythm.

Surgery

Your doctor may recommend surgery to repair or replace the tricuspid valve if you have tricuspid valve regurgitation and you're experiencing signs or symptoms, or your heart size begins to enlarge and heart function begins to decrease. In some cases, your doctor may recommend surgery if you have severe tricuspid valve regurgitation and you're experiencing mild or no symptoms, but your heart size is enlarging. Your doctor will evaluate you and determine if you're a candidate for heart valve repair or replacement.

If you have tricuspid valve regurgitation and you're having heart surgery to treat existing conditions on the left side of your heart, such as mitral valve surgery, your doctor may recommend that you have tricuspid valve surgery at the same time.

Surgical options include:

Heart valve repair

Surgeons repair a heart valve rather than replace the valve when possible. Your surgeon may perform valve repair by separating tethered valve leaflets, by closing holes (fenestrations) in leaflets and by reshaping the valve leaflets so that they can make contact with each other and prevent backward flow. The repair is usually tightened and stabilized by placing a partial band around the valve (annulus) and is referred to as an annuloplasty.

Some surgeons perform cone repair, a newer form of tricuspid valve repair, to repair tricuspid valves in people with Ebstein's anomaly. In the cone reconstruction, surgeons separate the leaflets of the tricuspid valve from the underlying heart muscle. The leaflets are then rotated and reattached, creating a "leaflet cone."

Repair leaves you with your own functioning tissue, which is resistant to infection and doesn't require blood-thinning medication, and optimizes function of the right ventricle.

Heart valve replacement

If your tricuspid valve can't be repaired, your surgeon may replace it with a biological or mechanical valve.

In tricuspid valve replacement, your surgeon replaces the valve by removing part of the deformed valve and inserting a biological tissue (bioprosthetic) valve. Mechanical valves are used less often to treat tricuspid valve regurgitation, in contrast to replacement of the mitral or aortic valves. If you have a mechanical valve, you'll need to take blood-thinning medications for life to reduce the risk of blood clots forming on the valve.

In some cases, if your bioprosthetic valve is no longer working, doctors may conduct a catheter procedure to replace the original prosthetic valve. In this procedure, doctors insert a catheter with a balloon at the end into a blood vessel in your neck or leg and thread it to the heart using imaging. A valve is inserted through the catheter and guided to the heart. Doctors then inflate the balloon in the bioprosthetic valve in the heart, and insert the new replacement valve into the preexisting bioprosthetic valve that is no longer functioning. The new valve is then expanded and anchored against the old bioprosthetic valve.

Maze procedure

If you have fast heart rhythms, your surgeon may perform the maze procedure during valve repair or replacement to correct the fast heart rhythms. In this procedure, a surgeon makes small incisions in the upper chambers of your heart to create a pattern or maze of scar tissue. Because scar tissue doesn't conduct electricity, it interferes with stray electrical impulses that cause some types of fast heart rhythms. Extreme cold (cryotherapy) or radiofrequency energy also may be used to create the scars.

Catheter ablation

If you have fast or abnormal heart rhythms, your doctor may perform catheter ablation. In this procedure, your doctor threads one or more catheters through your blood vessels to your heart. Electrodes at the catheter tips can use heat, extreme cold or radiofrequency energy to damage (ablate) a small spot of heart tissue and create an electrical block along the pathway that's causing your arrhythmia.

Pregnancy and tricuspid valve regurgitation

Women with tricuspid valve regurgitation who wish to become pregnant should discuss it with their doctors before becoming pregnant. If you have severe tricuspid valve regurgitation, you should be evaluated before you become pregnant by a cardiologist trained in treating women with heart valve disease during pregnancy. If your condition is due to a congenital heart condition, such as Ebstein's anomaly, you need to be evaluated by a doctor trained in congenital heart disease. Discuss the risks with your doctor.

A successful pregnancy is possible. However, if you have severe tricuspid valve regurgitation, you should be cared for by a multidisciplinary team of doctors experienced in treating women with heart valve disease during pregnancy.

Preparing for an appointment

If you don't have any signs or symptoms of heart trouble, the doctor may suspect a problem only if he or she is doing a test, such as an echocardiogram, for another heart condition. If your doctor suspects a problem, your doctor will likely refer you to a doctor who specializes in treating heart conditions (cardiologist) to diagnose your condition.

It's a good idea to arrive well-prepared for your appointment. Here's some information to help you get ready, and what to expect from your doctor.

What you can do

  • Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if you need to do anything in advance, such as restrict your diet.
  • Write down any signs and symptoms you are experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Make a list of any medications, vitamins or supplements that you're taking.
  • Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Request that a copy of previous medical records be forwarded to your current doctor, if you're changing doctors. If you have had a previous operation, a copy of the operation report is very helpful.
  • Write down questions to ask the doctor.

Your time with the doctor is limited, so preparing a list of questions can help you make the most of your time together. For tricuspid valve regurgitation, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • What kinds of tests do I need? Do these tests require any special preparation?
  • I feel OK. Do I even need treatment?
  • What treatments are available, and which do you recommend?
  • Does the surgeon have experience with repairing the valve?
  • What types of side effects can I expect from treatment?
  • Will I need surgery on the valve again in the future?
  • Are there any alternatives to the primary approach that you're suggesting?
  • I have other health conditions. How can I best manage these conditions together?
  • Are there any activity restrictions that I need to follow?
  • Is there a generic alternative to the medicine you're prescribing me?
  • Are there any brochures or other printed material that I can take home with me?
  • Can you recommend any websites for more information on my condition?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you first begin experiencing symptoms?
  • Have your symptoms been continuous or occasional?
  • Does anything seem to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?
  • If you have already been diagnosed with tricuspid valve regurgitation, when and where was the diagnosis made?
  • Have you had any surgery or ever been hospitalized?
  • What medications are you taking?

Lifestyle and home remedies

Your doctor may recommend that you make some lifestyle changes to improve your heart health and to live with tricuspid valve regurgitation, including:

  • Eat a heart-healthy diet. Eat a variety of fruits and vegetables, whole grains, and lean proteins. Avoid saturated fats and trans fats, sugar, salt, and refined grains.
  • Exercise. Exercise can help improve your heart health. However, check with your doctor before you begin an exercise plan, especially if you're interested in participating in competitive sports. The amount and type of exercise your doctor recommends for you may depend on your condition, if you have other heart valve conditions and if your condition is caused by other conditions.
  • Prevent infective endocarditis. If you have had a heart valve replaced, your doctor may recommend you take antibiotics before dental procedures to prevent an infection called infective endocarditis. Check with your doctor to find out if he or she recommends that you take antibiotics before dental procedures.
  • Discuss pregnancy. If you're a woman with tricuspid valve regurgitation and you're considering becoming pregnant, discuss family planning with your doctor prior to becoming pregnant. If you have severe tricuspid valve regurgitation, you'll need to be monitored by a cardiologist and medical team experienced in treating women with heart valve conditions during pregnancy.
  • See your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider. Let your doctor know if you have any changes in your signs or symptoms.

Coping and support

If you have tricuspid valve regurgitation, here are some steps that may help you cope:

  • Take medications as prescribed. Take your medications as directed by your doctor.
  • Get support. Having support from your family and friends can help you cope with your condition. Ask your doctor about support groups that may be helpful.
  • Stay active. It's a good idea to stay physically active. Your doctor may give you recommendations about how much and what type of exercise is appropriate for you.

Last updated: June 29th, 2016

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