Tricuspid regurgitation differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2] Basir Gill, M.B.B.S, M.D.[3]

Overview

The blowing holosystolic murmur of tricuspid regurgitation must be distinguished from the murmur of mitral regurgitation and a ventricular septal defect.

Differentiating Tricuspid regurgitation from other Diseases

When diagnosing the mechanism of secondary TR, clinicians must differentiate between atrial and ventricular etiologies; atrial secondary TR occurs without significant right ventricular (RV) remodeling and is often seen in heart failure with preserved ejection fraction (HFpEF).^[1] CIED-related TR must be differentiated from other causes of secondary TR by determining if the lead is directly interfering with the valve apparatus through impingement, perforation, or avulsion.^[2]

Severe tricuspid regurgitation may mimic constrictive pericarditis or restrictive cardiomyopathy due to similar hemodynamic features, including elevated right-sided filling pressures and systemic venous congestion. Comprehensive imaging and, in selected cases, invasive hemodynamic assessment may be required for differentiation.^[3]

Tricuspid Regurgitation	Mitral Regurgitation	VSD	Constrictive Pericarditis^[4]
Can be best heard over the fourth intercostal area at left sternal border. The intensity can be accentuated following inspiration (Carvallo’s sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein’s anomaly, carcinoid disease, or prior right ventricular infarction.	The murmur in mitral regurgitation is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary mitral regurgitation. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe mitral regurgitation.	The holosystolic murmur can be best heard over the left third and fourth intercostal spaces and along the sternal border. When the shunt becomes reversed (Eisenmenger’s syndrome), the murmur may be absent and S₂ can become markedly accentuated and single.	Severe TR has been documented to mimic some hemodynamic findings in constrictive pericarditis, with right heart catheterization demonstrating a constrictive physiology. Echocardiography, CT thorax, and cardiac MRI are useful for ruling out pericardial pathology.

References

↑ Hahn, R. T., Lindenfeld, J., Böhm, M., Edelmann, F., Lund, L. H., Lurz, P., Metra, M., Tedford, R. J., Butler, J., & Borlaug, B. A. (2024). Tricuspid regurgitation in patients with heart failure and preserved ejection fraction: JACC state-of-the-art review. Journal of the American College of Cardiology, 84(2), 195–212. https://doi.org/10.1016/j.jacc.2024.04.047
↑ Andreas, M., Burri, H., Praz, F., Soliman, O., Badano, L., Barreiro, M., Cavalcante, J. L., de Potter, T., Doenst, T., Friedrichs, K., Hausleiter, J., Karam, N., Kodali, S., Latib, A., Marijon, E., Mittal, S., Nickenig, G., Rinaldi, A., Rudzinski, P. N., … Leclercq, C. (2024). Tricuspid valve disease and cardiac implantable electronic devices. European Heart Journal, 45(5), 346–365. https://doi.org/10.1093/eurheartj/ehad783
↑ Hahn RT (May 2023). “Tricuspid Regurgitation”. N Engl J Med. 388 (20): 1876–1891. doi:10.1056/NEJMra2216709. PMID 37195943 Check |pmid= value (help).
↑ Ozpelit E, Akdeniz B, Ozpelit ME, Göldeli O (2014). “Severe tricuspid regurgitation mimicking constrictive pericarditis”. Am J Case Rep. 15: 271–4. doi:10.12659/AJCR.890092. PMC 4079647. PMID 24995118.

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[1] Hahn, R. T., Lindenfeld, J., Böhm, M., Edelmann, F., Lund, L. H., Lurz, P., Metra, M., Tedford, R. J., Butler, J., & Borlaug, B. A. (2024). Tricuspid regurgitation in patients with heart failure and preserved ejection fraction: JACC state-of-the-art review. Journal of the American College of Cardiology, 84(2), 195–212. https://doi.org/10.1016/j.jacc.2024.04.047

[2] Andreas, M., Burri, H., Praz, F., Soliman, O., Badano, L., Barreiro, M., Cavalcante, J. L., de Potter, T., Doenst, T., Friedrichs, K., Hausleiter, J., Karam, N., Kodali, S., Latib, A., Marijon, E., Mittal, S., Nickenig, G., Rinaldi, A., Rudzinski, P. N., … Leclercq, C. (2024). Tricuspid valve disease and cardiac implantable electronic devices. European Heart Journal, 45(5), 346–365. https://doi.org/10.1093/eurheartj/ehad783

[TR1-3] Hahn RT (May 2023). “Tricuspid Regurgitation”. N Engl J Med. 388 (20): 1876–1891. doi:10.1056/NEJMra2216709. PMID 37195943 Check |pmid= value (help).

[pmid24995118-4] Ozpelit E, Akdeniz B, Ozpelit ME, Göldeli O (2014). “Severe tricuspid regurgitation mimicking constrictive pericarditis”. Am J Case Rep. 15: 271–4. doi:10.12659/AJCR.890092. PMC 4079647. PMID 24995118.

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