(February 11, 2009 - Insidermedicine) Dr. Robert Bonow, MD, 2002-2003 President of the American Heart Association, discusses what he would do if he received a diagnosis of tricuspid regurgitation. Dr. Bonow is Chief of the Division of Cardiology and the Goldberg Distinguished Professor at Northwestern University's Feinberg School of Medicine.
At the American heart association scientific sessions at New Orleans we got a chance to catch up with doctor Dr. Bonow who is the Chief of the Division of Cardiology and the Goldberg Distinguished Professor at Northwestern University's Feinberg School of Medicine. Dr. Bonow is also the former president of the AHA.
If I had been diagnosed with tricuspid regurgitation…
Dr. Bonow: This could be something quite significant. The usual reason why the tricuspid valve leaks or has regurgitation is not a problem with the valve itself, it’s a problem with the chamber that connects the valve to the right atrium. Usually it is caused by other conditions that elevate the pressures on the right side of the heart, that make the right ventricle enlarge, stretching the tricuspid valve so that the leaflets can no longer connect and therefore the valve leaks. They’re actually the most common cause of tricuspid regurgitation. Its not the valve, it’s the higher pressures in the lungs which could be related to heart failure, it could be related to a valve problem on the left side of the heart, predominantly, mitral regurgitation is the leading cause of tricuspid regurgitation. So you should see a specialist for this to make the correct diagnosis of the underlying cause for the tricuspid regurgitation.
Is tricuspid regurgitation an urgent matter?
Dr. Bonow: Usually not that urgent as it is usually a reflection of a chronic process. Not the kind of thing where you need to go to an emergency room immediately. But you should see either a very good internist, who knows how to make the other diagnosis here, or get sent to a cardiovascular specialist who can try to figure out what the underlying cause for this really is.
What does the physical examination consist of?
Dr. Bonow: As the tricuspid regurgitation is usually not only related to the valve, clearly the leg swelling is part of this, but if this is related more to higher pressures in your lungs there may have shortness of breath. And if the regurgitation is of significance, a lot of blood is going backwards, you may not have a lot of blood going forward therefore one might be tired or fatigued. So the predominant symptoms here to look out for would be fatigue, shortness of breath, as well as leg swelling.
What diagnostic tests should be performed?
Dr. Bonow: The most important test here, in addition to a skilled doctor listening to your heart to detect any murmurs in the heart and whether there is any fluid in the lungs, the most important test would be chest x-ray and maybe even more important then that an echocardiogram, which is ultrasound test that can evaluate the structure and function of the heart.
What is the implication of tricuspid regurgitation
Dr. Bonow: So the implication here is that this may be a late finding of something that’s been going on for a long time. For example with the mitral valve that is causing the problem, causing back up or pressure into the lungs, that occurs first and only when the pressures go high does that actually cause a tricuspid regurgitation to begin to leak. So the implication is you’re maybe dealing with something which is not only chronic but something which is pretty far advanced. Now having said that, there are some causes of regurgitation of the tricuspid valves that are caused by the valve itself. Trauma for example is a leading cause for that. The tricuspid valve is right below your breast bone and trauma to the chest, a steering wheel injury is for example a common cause of isolated tricuspid insufficiency. That is not necessarily a chronic process but the kind of thing that could be evaluated pretty readily.
What is the management of tricuspid regurgitation?
Dr. Bonow: The management of tricuspid regurgitation and the leg swelling that results from that first and foremost might be a water pill, a diuretic to get rid of the fluid. But then we need to find the right diagnosis for the underlying cause for this that might be again a valve problem on the left side of the heart that might require surgery on the valve, it may be related to heart failure, weakening of the heart muscle on the left side causing high pressures backing up into the lungs and that requires intensive and pretty good medical therapy that could reverse the situation. So there are medicines that one could use that are quite common for heart failure patients not only the water pills but also ACE inhibitors, beta-blockers in particular, that can improve the function of the heart.
What are the surgical procedures for tricuspid regurgitation?
Dr. Bonow: The procedures one would do would again be to determine whether a surgical procedure for valve on the left side of the heart that might be the primary problem could be effective and lower the pressure in the lungs. But usually for significant tricuspid regurgitation, even say a valve problem on the left side of the heart, raising pressures in the lungs making the tricuspid valve leak. One would have to do a procedure at the same time to fix the tricuspid valve. That’s what’s called an angioplasty where you pull the valve closer together so that the stretching that has occurred to make the valve leak recovers, so that it can now begin to function more normally.
What are the risks of these procedures?
Dr. Bonow: Well surgical procedures of any kind can be risky therefore one would have to get advice maybe from more than one doctor about the correct approach, a mitral valve repair is relatively a low risk procedure but if you’re already at the point where you have heart failure and tricuspid insufficiency then this might be a little more serious. But in a highly experienced surgical center, the risks of repairing a mitral valve and tricuspid valve together those risks are usually under 5% and maybe closer to 1%
Dr. Bonow: Now if I had tricuspid regurgitation with significant leg swelling, I’d be very concerned because this usually is a marker of something else going on that’s making the valve get to stretched, higher pressures in the lungs, maybe it’s a lung problem or maybe I have heart failure, I need to get that evaluated, what’s my left ventricular function and do I have other valve issues going on? Do I have mitral valve regurgitation causing higher pressures in my lungs making my right ventricle dilate so I would get to a cardiologist very quickly, I’d get a echocardiogram done to determine what’s the pressure in my lungs, what are the valves doing and very importantly what’s my left ventricular function as well as my right ventricular function. I want to get this taken care of pretty promptly.