The tricuspid valve is a heart valve that connects the two chambers of the right side of the heart: the right atrium and right ventricle. Tricuspid regurgitation (TR) occurs when this valve doesn’t close properly, which can lead to serious effects on the rest of the body.

What does this have to do with pulmonary hypertension (PH)? Most people with PH develop TR over time. In this article, we’ll explore the connection between these two conditions and what it means for those living with PH.

What Is Tricuspid Regurgitation?

Normally, as the heart beats, blood flows from the right atrium into the right ventricle. When the tricuspid valve cannot close (due to valve damage or large blood pressure in pulmonary arteries), blood from the ventricle backs up, or regurgitates, into the atrium with every heartbeat. As a result, the heart pumps less blood into the lungs to receive oxygen. Then, blood volume and pressure increase in the right atrium. Ultimately, the heart has to work harder and encounters more stress. While mild tricuspid valve regurgitation can go undetected, severe TR can cause or worsen ongoing heart and lung disease.

What Causes Tricuspid Regurgitation?

Occasionally, TR occurs because of a congenital (birth) defect or an infection in the tricuspid valve, but it more commonly results from other heart conditions. These include other valve disorders and left-sided heart failure, as well as lung disorders like chronic obstructive pulmonary disease (COPD) and PH.

Does pulmonary hypertension cause regurgitation? Pulmonary hypertension, an umbrella term describing high blood pressure in the lungs' arteries, is a major risk factor for developing TR.

What’s the Relationship Between Tricuspid Regurgitation and PAH?

When someone has PH, the right side of the heart works harder to pump blood into the lungs. Severe PH can cause the right ventricle to enlarge, a condition known as hypertrophy. Over time, this enlargement can affect how the tricuspid valve works, leading to regurgitation.

Why does pulmonary hypertension cause tricuspid regurgitation? PH and TR are closely linked, with each condition making the other worse. When the right ventricle enlarges, it can affect how the tricuspid valve works. A poorly functioning valve forces the heart to work harder, which can make PH worse. Severe TR is tied to worsening PH and a higher risk of serious complications, including increased death rates.

Risk Factors for Tricuspid Regurgitation

TR is classified as either primary or secondary based on its underlying cause.

Primary Tricuspid Regurgitation

Primary, or organic, TR develops when there is direct damage to parts of the valve. Congenital conditions, infections, and trauma caused by the implantation of a pacemaker are all causes of this primary type of tricuspid valvular heart disease.

Secondary Tricuspid Regurgitation

Secondary, or functional, TR occurs when there is stretching or dilatation (widening or enlargement) of the part of the valve called the annulus, which is the ring of tissue where the valve’s leaflets sit. The leaflets are the parts that close together, and when their base becomes distended (stretched or swollen), they no longer close properly.

Functional TR can develop as a result of PH, as well as from left-sided heart disease, and so the conditions share many risk factors. The severity of secondary TR usually depends on how advanced the underlying PH or left-sided heart disease is.

Heart conditions that alter blood flow between the heart and lungs and increase pulmonary arterial pressure are potential causes of PH (and therefore TR). Mitral valve diseases —including mitral regurgitation, in which the valve between the left atrium and left ventricle becomes leaky, and mitral valve stenosis, when the valve narrows — are risk factors for PH.

Symptoms of Tricuspid Regurgitation

Many people with mild TR have no symptoms. If their condition becomes severe, they may experience signs and symptoms, which include:

• Heart murmur — An abnormal sound heard during a heartbeat
• Atrial fibrillation — Heart rhythm abnormalities
• Ascites or edema — Swelling in the abdomen or legs
• Dyspnea — Shortness of breath during activity
• Jugular vein distension — Strong pulse in the neck or abdomen
• Hepatomegaly — Enlarged liver
• Fatigue — A feeling of extreme tiredness
• Weakness — Reduced strength

Because TR is often the result of another heart condition, such as PH, additional symptoms can arise from that underlying condition. Common symptoms associated with PH overlap with TR, such as shortness of breath, fatigue, and weakness.

Diagnosing Tricuspid Regurgitation

The symptoms of TR are similar to those of PH and other cardiopulmonary diseases (like shortness of breath or fatigue), and TR can worsen related heart and lung conditions. These factors make it important to identify TR when other conditions, such as PH, are suspected.

Because symptoms are often not present in mild or even moderate cases, identifying TR early is challenging but important. Several diagnostic tests can help confirm and monitor this condition.

A doctor may suspect TR based on a patient’s history and symptoms, or they may notice a characteristic heart murmur during a physical exam.

Echocardiogram

The primary test to examine the heart for TR is a Doppler echocardiogram. This test uses sound waves, to create a picture of the heart as it beats. These sound waves allow the doctor to visualize how the heart beats and examine how the blood moves through the heart. The most common form of echocardiographic assessment is transthoracic echocardiography, in which the measurements are taken by placing an ultrasound probe on the person’s chest.

A doctor might instead use transesophageal echocardiography, which is more invasive. During a transesophageal echocardiogram, a thin tube is placed down into the esophagus through the mouth. This method gives the doctor a clearer view of how the tricuspid valve is working by avoiding anything blocking the ribs or lungs.

During the echocardiogram, the doctor will check for problems with how the ventricles are working, using measures like tricuspid annular plane systolic excursion (TAPSE). TAPSE is used to evaluate how well the right ventricle is functioning and identify causes of tricuspid regurgitation, such as right ventricle enlargement. Additionally, the doctor will examine the tricuspid valve’s shape and movement, as well as the way blood flows through the valve as the heart beats.

Electrocardiogram

A doctor may also recommend an electrocardiogram (ECG or EKG), a noninvasive procedure that measures the electrical activity of the heart. An ECG can help detect heart strain as well as abnormal heart rhythms.

Echocardiography and ECG are also used to diagnose PH. If PH is suspected, an additional test called right heart catheterization is performed. This test can show doctors where blood pressure is high, which can assist in making a specific diagnosis and treatment plan. Although this test is the gold standard for diagnosing PH, it’s not often recommended for diagnosing TR. In some cases, however, it may be used to determine the cause of the tricuspid malfunction.

Treatment of Pulmonary Hypertension and Tricuspid Regurgitation

The main goal in managing TR is to treat any underlying conditions. When PH and TR occur together, this means treating PH with medications that specifically lower blood pressure in the lungs. In cases of left-sided heart disease, treatments like beta-blockers and diuretics may be used to reduce strain on the heart and lower the body’s blood pressure. Medications may also be used to treat the complications of TR, such as abnormal heart rhythms, heart failure, and blood clots.

If a person’s TR is severe or contributing to heart failure, a doctor may recommend surgical intervention, which may involve valve repair or replacement. Tricuspid valve surgery is sometimes performed during surgery for related heart conditions, such as mitral valve surgery. There has recently been advancement in minimally invasive treatment of TR.

Management of TR and PH is difficult — both diseases are complex. Regular follow-up with a cardiac care team is important because the presence of both conditions can cause major health problems and an increased risk of death when not treated properly. The good news is that TR is becoming more recognized, and researchers are urging health care providers to look for risk factors during routine workups for other heart conditions.

Talk With Others Who Understand

On myPHteam, the social network for people with pulmonary hypertension and their loved ones, more than 55,000 members come together to ask questions, give advice, and share their stories with others who understand life with pulmonary hypertension.

Are you living with tricuspid regurgitation or pulmonary hypertension? Have you experienced any symptoms related to tricuspid regurgitation? Share your experience in the comments below, or start a conversation by posting on your Activities page.