Q. Clinical Features of tricuspid regurgitation?

Patients with severe primary tricuspid regurgitation will have symptoms of fatigue, dyspnoea and effort intolerance, abdominal fullness and distension. In the absence of left heart diseases leading to tricuspid regurgitation, orthopnoea and PND do not occur. Physical examination will show elevated mean jugular venous pressure with prominent ‘v' waves and sharp v-y collapse in the absence of tricuspid stenosis. Pulsatile hepatomegaly is often noted. Pan systolic murmur of tricuspid regurgitation is heard at lower left sternal border and it typically increases with inspiration due to increased venous return. In about 20 per cent of patients the murmur may not be audible. Lateral head bobbing is sometimes obvious at bedside. This is in contrast to vertical head bobbing that may be seen in aortic regurgitation. The height of ‘v' waves depends upon the compliance and size of right atrium and may not exactly reflect severity of regurgitation. Systolic murmurs of low pressure TR tend to be early systolic in contrast to those of high pressure TR. This is because in the former, right atrial and right ventricular systolic pressure tend to equalize in early systole and regurgitation stops by mid systole. Intensity of murmur does not correlate with severity of regurgitation. Musical murmurs of TR may produce loud murmurs. In inspiration TR murmur typically increase due to increased venous return and this is called Carvello's sign. This may not be seen in patients with right heart failure since failing right ventricle's output cannot be increased further with inspiration.