AKT · Cardiovascular/Valves & endocardiumlow yield

Right heart valve disease

Tricuspid/pulmonary valve dysfunction — functional, infective, congenital or carcinoid

Overview

Disease of the tricuspid and pulmonary valves. Tricuspid regurgitation is usually functional (secondary to RV dilatation/pulmonary hypertension) but can be from endocarditis (IV drug use), rheumatic disease or carcinoid. Pulmonary stenosis is usually congenital. Right-sided lesions present with systemic venous congestion rather than pulmonary symptoms.

Recognise

Tricuspid regurgitation: pansystolic murmur at the left lower sternal edge louder on inspiration; giant V waves in the JVP; pulsatile hepatomegaly, ascites, peripheral oedema
IV drug use + fever + new tricuspid murmur → right-sided endocarditis (with septic pulmonary emboli)
Carcinoid heart disease: tricuspid regurgitation + pulmonary stenosis from serotonin-secreting tumour

Red flags

Right-sided endocarditis in an IV drug user → blood cultures, echo, antibiotics ± surgery
Severe TR with progressive right heart failure → consider intervention

Differentials & how to tell them apart

Mitral regurgitationapical, radiates to axilla, not inspiratory-accentuated

Constrictive pericarditisraised JVP with Kussmaul's sign, calcified pericardium

Right heart failure from lung disease (cor pulmonale)primary respiratory cause

Investigations

Echo (valve mechanism, RV size/function, pulmonary pressures); ECG; blood cultures (endocarditis); urinary 5-HIAA if carcinoid suspected; assess the left heart/pulmonary cause of functional TR.

Management

Treat the cause + diuretics; valve surgery for severe primary disease

1Characterise on echo and identify the cause (functional vs endocarditis vs carcinoid vs congenital). Treat the driver and relieve congestion with diuretics.Gate: IV drug user with fever and a new tricuspid murmur → right-sided infective endocarditis: blood cultures and antibiotics, surgery for specific indications.
2Severe primary right-sided valve disease → repair/replacement, often combined with left-sided valve surgery.

Treat the underlying cause (left heart disease/pulmonary hypertension) — functional TR often improves when the driver is treated

Diuretics for congestion — relieve systemic venous overload

Antibiotics ± surgery for endocarditis; somatostatin analogues for carcinoid — cause-specific therapy

Valve repair/replacement — for severe primary disease, often at the time of left-sided valve surgery

Key points

Pansystolic murmur at the left lower sternal edge that gets LOUDER on inspiration + giant JVP V waves + pulsatile liver = tricuspid regurgitation. IV drug use + fever + tricuspid murmur = right-sided endocarditis. TR + pulmonary stenosis = carcinoid heart disease.

Monitor & prognosis

Echo, right heart failure signs, treat the underlying driver.

Functional TR tracks the underlying disease; endocarditis/carcinoid depend on the primary process.

Source: NICE NG208; ESC