What does trace mitral and tricuspid regurgitation mean

This article was updated in 2018

March 7, 2013 — The American Society of Echocardiography (ASE) has released a list of five interventions whose appropriateness physicians and patients should discuss as part of Choosing Wisely, an initiative of the ABIM Foundation, along with Consumer Reports. First in the list, they ask that patients and their doctors talk about the real need for additional echocardiograms when there are only minor signs of heart valve leakage.

Do not order follow up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram.

As access to healthcare information has become more readily available to concerned patients, a growing number of doctors have become involved in evaluating, ordering and caring for patients with a wider range of heart health problems rather than sending them directly to a specialist to follow these issues. Additionally, the technology associated with medical testing has improved and miniaturized, leading to increased utilization of echocardiography to quickly and painlessly evaluate the patient’s heart. With the increase in testing and improvements in technology, it is now common for physicians to find trace valve regurgitation, or leakage, that in the past no one would have been aware was present. This may lead to anxiety, misleading results and more questions for a patient who has a limited understanding of echo reporting.

Trace regurgitation is a very mild leak of a heart valve, which occurs when a valve does not close tightly, allowing blood to leak backward in your heart. Nearly all of the normal population will have a finding of some trivial or mild degree of regurgitation of one, two or three heart valves on a normal echocardiogram. This is sometimes called “physiologic” regurgitation by the doctor interpreting the echocardiogram. In most cases, a doctor, used to seeing these types of patients, will not even mention this finding to the patient as a way of avoiding the anxiety associated with this disclosure, which would be an essentially normal finding in most patients.

Trace, physiologic, and in most cases, mild regurgitation of the mitral, tricuspid or pulmonic valve reported on an echocardiogram requires no immediate or long term follow up. Following up on these findings with additional testing should only be done if you and your doctor believe you have signs and symptoms of the leakage progressing or getting worse. These signs may include a murmur (an abnormal sound when the doctor listens to your heart), fatigue, chest pain, shortness of breath, or extra, or funny, heart beats.

If a patient has trace regurgitation of the aortic valve, their doctor may choose to follow the regurgitation with future echocardiograms and additional physical examinations.

The goal of Choosing Wisely is to promote conversations between physicians and patients about utilizing the most appropriate tests and treatments and avoiding care that may provide no benefit.

ASE’s testing cardiovascular care scenarios were chosen based on the highest likelihood of improving patient care and reducing inappropriate test use. Leaders in the organization transformed the scenarios into plain language and produced the clinical explanations for each procedure. In particular, ASE’s cardiovascular care experts, reviewed the ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriateness Use Criteria for Echocardiography (AUC), which was published in March 2011. Here is a link to the most current version of the ASE AUC guidelines.

ASE encourages all medical professionals engaged in cardiovascular care to read the

“Five Things Physicians and Patients Should Question” lists at www.choosingwisely.org, and to engage their patients in conversations about reducing inappropriate tests and procedures with a goal of improving care and avoiding harm.

Consumer Reports, along with a coalition of consumer partner organizations, is also a part of the Choosing Wisely effort and is working with many of the societies to help patients understand the tests and treatments that are right for them.

For more information: www.asecho.org, www.choosingwisely.org

Related Content:

ASE Releases List of Five Tests or Procedures That May Be Overused

Top Echocardiography News and Video From ASE 2017

A Glimpse Into the Future of Cardiac Ultrasound

Blood that flows between different chambers of your heart must pass through a heart valve. These valves open up enough so that blood can flow through. They then close, keeping blood from flowing backward.

The tricuspid valve separates the right lower heart chamber (the right ventricle) from the right upper heart chamber (right atrium).

Tricuspid regurgitation is a disorder in which this valve does not close tight enough. This problem causes blood to flow backward into the right upper heart chamber (atrium) when the right lower heart chamber (ventricle) contracts.

An increase in size of the right ventricle is the most common cause of this condition. The right ventricle pumps blood to the lungs where it picks up oxygen. Any condition that puts extra strain on this chamber can cause it to enlarge. Examples include:

• Abnormally high blood pressure in the arteries of the lungs which can come from a lung problem (such as COPD, or a clot that has traveled to the lungs) 
• Other heart problem such as poor squeezing of the left side of the heart
• Problem with the opening or closing of another one of the heart valves

Tricuspid regurgitation may also be caused or worsened by infections, such as:

• Rheumatic fever
• Infection of the tricuspid heart valve, which causes damage to the valve

Less common causes of tricuspid regurgitation include:

• A type of heart defect present at birth called Ebstein anomaly.
• Carcinoid tumors, which release a hormone that damages the valve.
• Marfan syndrome.
• Rheumatoid arthritis.
• Radiation therapy.
• Past use of a diet pill called "Fen-Phen" (phentermine and fenfluramine) or dexfenfluramine. The drug was removed from the market in 1997.

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The health care provider may find abnormalities when gently pressing with the hand (palpating) on your chest. The provider may also feel a pulse over your liver. The physical exam may show liver and spleen swelling.

Listening to the heart with a stethoscope may reveal a murmur or other abnormal sounds. There may be signs of fluid buildup in the abdomen.

An ECG or echocardiogram may show enlargement of the right side of the heart. Doppler echocardiography or right-sided cardiac catheterization may be used to measure blood pressure inside the heart and lungs.

Other tests, such as CT scan or MRI of the chest (heart), may reveal enlargement of the right side of the heart and other changes.

Treatment may not be needed if there are few or no symptoms. You may need to go to the hospital to diagnose and treat severe symptoms.

Swelling and other symptoms of heart failure may be managed with medicines that help remove fluids from the body (diuretics).

Some people may be able to have surgery to repair or replace the tricuspid valve. Surgery is most often done as part of another procedure.

Treatment of certain conditions may correct this disorder. These include:

• High blood pressure in the lungs
• Swelling of the right lower heart chamber

Surgical valve repair or replacement most often provides a cure in people who need an intervention.

The outlook is poor for people who have symptomatic, severe tricuspid regurgitation that cannot be corrected.

Call your provider if you have symptoms of tricuspid regurgitation.

People with abnormal or damaged heart valves are at risk for an infection called endocarditis. Anything that causes bacteria to get into your bloodstream may lead to this infection. Steps to avoid this problem include:

• Avoid unclean injections.
• Treat strep infections promptly to prevent rheumatic fever.
• Always tell your health care provider and dentist if you have a history of heart valve disease or congenital heart disease before treatment. Some people may need to take antibiotics before having a procedure.

Prompt treatment of disorders that can cause valve or other heart diseases reduces your risk of tricuspid regurgitation.

Tricuspid insufficiency; Heart valve - tricuspid regurgitation; Valvular disease - tricuspid regurgitation

Carabello BA. Valvular heart disease. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 66.

Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e1195. PMID: 28298458 pubmed.ncbi.nlm.nih.gov/28298458/.

Pelikka PA. Tricuspid, pulmonic, and multivalvular disease. In: Zipes DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 70.

Rosengart TK, Anand J. Acquired heart disease: valvular. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 60.

Updated by: Michael A. Chen, MD, PhD, Associate Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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