Difference between revisions of "Tricuspid regurgitation differential diagnosis"

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(Overview)
(Differentiating Tricuspid regurgitation from other Diseases)
 
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*[[Left ventricular function]] can be assessed by determining the [[apical impulse]].  
 
*[[Left ventricular function]] can be assessed by determining the [[apical impulse]].  
 
*A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]].  
 
*A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]].  
*A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]].
 
|
 
*The [[holosystolic murmur]] can be best heard over the left third and fourth intercostal spaces and along the sternal border.
 
*When the shunt becomes reversed ([[Eisenmenger's syndrome]]), the murmur may be absent and S<sub>2</sub> can become markedly accentuated and single.
 
|
 
*Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology.
 
|}
 
 
{| border="1"
 
|- style="padding: 0 5px; font-size: 100%; " align="center"
 
|'''Tricuspid Regurgitation'''
 
|'''Mitral Regurgitation'''
 
|'''VSD'''
 
|'''Constrictive Pericarditis'''<ref name="pmid24995118" />
 
|- style="font-size: 100; padding: 0 5px;"
 
|
 
*Can be best heard over the fourth intercostal area at [[left sternal border]].
 
*The intensity can be accentuated following [[inspiration]] ([[Carvallo's sign]]) due to increased regurgitant flow in [[right ventricular]] volume.
 
*Tricuspid regurgitation is most often secondary to [[pulmonary hypertension]].
 
*Primary tricuspid regurgitation is less common and can be due to bacterial [[endocarditis]] following [[IV drug use]], [[Ebstein's anomaly]], [[carcinoid disease]], or prior [[right ventricular infarction]].
 
|
 
*The [[murmur]] in [[mitral regurgitation]] is high pitched and best heard at the [[apex]] with diaphragm of the [[stethoscope]] with patient in the lateral decubitus position.
 
*[[Left ventricular function]] can be assessed by determining the [[apical impulse]].
 
*A normal or hyperdynamic [[apical impulse]] suggests good [[ejection fraction]] and primary [[mitral regurgitation]].
 
 
*A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]].
 
*A displaced and sustained [[apical impulse]] suggests decreased [[ejection fraction]] and chronic and severe [[mitral regurgitation]].
 
|
 
|
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*Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology.
 
*Severe TR has been documented to mimic some hemodynamic findings in [[constrictive pericarditis]], with [[right heart catheterization]] demonstrating a constrictive physiology. [[Echocardiography]], CT thorax, and [[cardiac MRI]] are useful for ruling out [[pericardium|pericardial]] pathology.
 
|}<br />
 
|}<br />
{| class="wikitable"
 
! rowspan="2" |Diseases
 
! rowspan="2" |History
 
! rowspan="2" |Symptoms
 
! rowspan="2" |Physical Examination
 
! rowspan="2" |Murmur
 
! colspan="4" |Diagnosis
 
! rowspan="2" |Other Findings
 
|- style="background: #DCDCDC; padding: 5px; text-align: center;"
 
!ECG
 
!CXR
 
!Echocardiogram
 
!Cardiac Catheterization
 
|-
 
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Stenosis]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Age ( Mitral annular calcification in older patients)
 
 
*[[Rheumatic fever]]
 
 
*[[Endocarditis]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Dyspnea on exertion]]
 
 
*[[Paroxysmal nocturnal dyspnea]]
 
 
*[[Orthopnea]]
 
 
*New onset [[atrial fibrillation]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Mitral facies
 
 
*Heart murmur
 
 
*[[JVD|Jugular vein distension]]
 
 
*Apical impulse displaced laterally or not palpable
 
 
*Diastolic thrill  at the apex
 
 
*Signs of heart failure in severe cases
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Diastolic murmur
 
 
*Low pitched
 
 
*Opening snap  followed by decrescendo-crescendo rumbling murmur
 
 
*Best heard with the bell of the stethoscope at apex at end-expiration in left lateral decubitus position
 
 
*Intensity increases after a [[valsalva maneuver]], after exercise and after increased after load (eg., squatting, isometric hand grip)
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[P mitrale]]
 
*[[Atrial  fibrillation]]: No P waves and irregularly irregular rhythm
 
 
*[[Right axis deviation]]
 
 
*Right ventricular hypertropy: Dominant R wave in V1 and V2
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Straightening of the left border of the heart suggestive of enlargement of the [[left atrium]]
 
 
*Double right heart border (Enlarged left atrium and normal right atrium)
 
 
*Prominent left atrial appendage
 
 
*Splaying of [[Carina|subcarinal angle]] (>120 degrees)
 
 
*Calcification of [[mitral valve]]
 
 
*[[Kerley B lines]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Reduced valve leaflet mobility
 
 
*Valve calcification
 
 
*Doming of mitral valve
 
 
*Valve thickening
 
*Enlargement of left atrium
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Right heart catheterization:'''
 
*[[Pulmonary capillary wedge pressure]] (left atrial pressure)
 
 
'''Left heart catheterization:'''
 
 
*Pressures in left ventricle
 
 
*Determines the gradient between the left and right atrium during ventricular diastole (marker of the severity of mitral stenosis)
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Hemoptysis]] ([[heart failure]])
 
 
*[[Ortner's syndrome]]
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Mitral Regurgitation]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[CAD]]
 
 
*[[MI]]
 
 
*[[Rheumatic fever]]
 
 
*[[Endocarditis]]
 
 
*[[Mitral valve prolapse]]
 
 
*[[Cardiomyopathy]]
 
 
*[[Radiation therapy]]
 
 
*Trauma
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Palpitations]]
 
 
*Symptoms of heart failure in severe cases
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Palpation'''
 
*Brisk carotid upstroke and hyperdymanic carotid impulse on palpation
 
 
*Apical impulse is displaced to left
 
 
*S3 and a palpable thrill
 
 
'''Auscultation'''
 
 
*Murmur
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Holosystolic murmur]]
 
 
*High pitched, blowing
 
 
*Radiates to axilla
 
 
*Best heard with the diaphragm of the stethoscope at apex in left lateral [[decubitus]] position
 
 
*Intensity increases with hand grip or squatting
 
 
*Decrease in intensity on standing or [[valsalva maneuver]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[P mitrale]] in lead II
 
*Increased QRS voltage
 
*[[Right axis deviation]]
 
*[[Atrial fibrillation]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Acute MR'''
 
*[[Kerley B lines]]
 
*No enlargement of cardiac silhouette
 
 
'''Chronic MR'''
 
 
*Enlarged cardiac silhouette
 
*Straightening of left heart border
 
*Splaying of subcarinal angle
 
*Calcification of mitral annulus
 
*Double right heart border
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Enlargement of left atrium and ventricle
 
*Identify valve abnormality
 
*Valve calcification
 
*Severity of regurgitation
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Grading of MR is done with left ventriculography
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Decompensated and acute MR may lead to [[heart failure]]
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial septal defect]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Frequent respiratory or lung infections
 
*[[Dyspnea]]
 
*Tiring when feeding (Infants)
 
*Shortness of breath on exertion
 
*[[Palpitations]]
 
*Swelling of feet
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Shortness of breath]]
 
*[[Fatigue]]
 
*[[Failure to thrive]]
 
*Swelling of feet and abdomen ([[Right heart failure]])
 
*[[Palpitations]]
 
*Respiratory infections
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Inspection'''
 
*Precordial bulge
 
*Precordial lift
 
 
'''Palpation'''
 
 
*Right ventricular impulse
 
*Pulmonary artery pulsations
 
*Thrill
 
 
'''Auscultation'''
 
 
*Murmur
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Midsystolic (ejection systolic) murmur
 
 
*Widely split, fixed S2
 
 
*Upper left sternal border
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Normal
 
*Prolonged PR interval
 
*[[Right bundle branch block]]
 
*ECG findings varies according to the underlying type of ASD
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Increased pulmonary markings
 
*[[Cardiomegaly]]
 
*Triangular appearance of heart
 
*Schimitar sign
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Gold standard test for diagnosis of atrial septal defect  (for more information click [[Atrial septal defect echocardiography]])
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Defect size
 
*Pulmonary venous return
 
*[[Pulmonary vascular resistance]]
 
*[[Pulmonary artery hypertension]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Asymptomatic until later part of their life
 
*May be associated with [[migraine with aura]]
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Atrial myxoma|Left Atrial Myxoma]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*[[Dyspnea]]
 
*[[Orthopnea]]
 
*[[Pulmonary edema]]
 
*Hyperpigmentation of skin and endocrine activity
 
*Cerebral [[embolism]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Symptoms may mimic mitral stenosis
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Skin'''
 
*Signs of an embolic phenomenon
 
*[[Raynaud's phenomenon]]
 
*Swelling
 
*Clubbing
 
 
'''Auscultation:'''
 
 
*Lung: Fine crepitations
 
 
*Heart: Characteristic "tumor plop"
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Early diastolic sound as "tumor plop"
 
 
*Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Often normal
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Often normal
 
 
'''Rare findings:'''
 
 
*[[cardiomegaly]]
 
*Left atrial enlargement
 
*tumor calcification etc.,
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Initial and most useful diagnostic study
 
*For more information click [[Myxoma echocardiography or ultrasound]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Useful to detect vascular supply of the tumor by the coronary arteries
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Associated with Carney complex (genetic predisposition)
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Prosthetic Valve Obstruction
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*History of valve replacement
 
*Systemic embolism
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Shortness of breath
 
*Fatigue
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Ausculation'''
 
Muffling of murmur
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Muffling or disappearance of prosthetic sounds
 
 
*Appearance of new regurgitant or obstructive murmur
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Degree of stenosis
 
*Assess thrombus size and location
 
*Differentiate between thrombus, [[pannus]] and vegetations
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Causes:
 
 
*Thrombus
 
*Pannus formation
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |[[Cor Triatriatum]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Dyspnea on exertion
 
*Recent onset of [[congestive heart failure]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Dsypnea on exertion
 
*Orthopnea
 
*Tachypnea
 
*Palpitations
 
*Growth failure
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
 
*Murmur
 
 
'''Other findings'''
 
 
*Signs of heart failure
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Diastolic murmur with loud P2
 
 
*No opening snap or a loud S1
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Non specific but may have
 
 
*[[Right axis deviation]]
 
*Right atrial enlargement
 
*[[Right ventricular hypertrophy]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Normal cardiac silhouette
 
*Hemodynamic changes similar to mitral stenosis (non specific findings)
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Direct visualization of membrane through the atrium
 
*+/- visualization of accessory chamber
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Normal left ventricular hemodynamic profile with a trans atrial gradient
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Types
 
 
*Cor triatriatum sinistrum
 
*Cor triatriatum dextrum
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Congenital Mitral Stenosis
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Respiratory distress shortly after birth
 
*Recurrent severe pulmonary infections
 
*Other associated congenital cardiovascular anamolies
 
*[[Atrial fibrillation]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Infants:'''
 
 
*Exhaustion and sweating on feeding
 
*Rapid breathing
 
*[[Failure to thrive]]
 
*Pulmonary infections
 
*Chronic cough
 
 
'''Older patients:'''
 
 
*Dyspnea
 
*Orthopnea
 
*Paroxysmal nocturnal dyspnea
 
*Peripheral edema
 
*Fatigue
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation'''
 
*Murmur
 
 
'''Other findings'''
 
 
*Signs of heart failure
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Mild-Moderate'''
 
*Loud S1
 
 
*Loud P2
 
 
*Low frequency diastolic murmur best heard at the apex
 
 
'''Severe'''
 
 
*Soft S1
 
 
*Loud pulmonic component of S2 with minimal respiratory splitting of S2
 
 
*Holodiastolic murmur with presystolic accentuation best heard at the apex
 
 
*Early diastolic murmur of pulmonic valve regurgitation
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Sharp P waves in leads I and II
 
*Inversion of P wave in lead III
 
*Marked Q waves in leads II and III
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Left atrial dilation
 
*Moderate enlargement of right heart
 
*Pulmonary venous congestion
 
*Esophageal compression
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Reduced valve leaflet mobility
 
*Left atrial size
 
*Severity of mitral stenosis
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |Very rare condition
 
|-
 
| colspan="10" |
 
|-
 
| style="vertical-align: top;background: #DCDCDC; padding: 5px; text-align: center;" |Supravalvular Ring Mitral Stenosis
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Other associated congenital heart defects
 
*Fatigue
 
*Frequent respiratory infections
 
*Failure to thrive
 
*Poor feeding
 
*Precocious congestive heart failure
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Shortness of breath
 
 
*Tachypnea
 
*Dyspnea
 
*Nocturnal cough
 
*Heamoptysis
 
*[[Syncope]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Auscultation:'''
 
Lungs: Fine, crepitant rales and rhonchi or wheezes may be present
 
 
Heart: Murmur
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*An apical mid diastolic murmur with presystolic accentuation
 
 
*No opening snap
 
 
*The murmur is more prominent if associated with [[VSD]] or [[PDA]]
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Left atrial and ventricular enlargement
 
*Alveolar edema
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Supramitral ring''':
 
 
*Associated with normal mitral valve apparatus
 
 
'''Intramitral ring:'''
 
 
*Hypomobility of the posterior leaflet
 
*Reduced interpapillary muscle distance
 
*Reduced chordal length
 
*Dominant papillary muscle
 
*Hypoplastic mitral annulus
 
 
(Difficult to visualize membrane <1mm in size)
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |
 
*Persistently elevated pulmonary venous pressures
 
*Increased pulmonary artery pressure
 
| style="vertical-align: top;background: #F5F5F5; padding: 5px;" |'''Types'''
 
*Supramitral
 
*Intramitral
 
 
It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister.
 
 
*Intramitral type is associated with shone complex
 
|}
 
 
==References==
 
==References==
 
{{Reflist|2}}
 
{{Reflist|2}}

Latest revision as of 17:52, 21 January 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fatimo Biobaku M.B.B.S [2]

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Overview

The blowing holosystolic murmur of tricuspid regurgitation must be distinguished from the murmur of mitral regurgitation and a ventricular septal defect.

Differentiating Tricuspid regurgitation from other Diseases

Tricuspid Regurgitation Mitral Regurgitation VSD Constrictive Pericarditis[1]
  • The holosystolic murmur can be best heard over the left third and fourth intercostal spaces and along the sternal border.
  • When the shunt becomes reversed (Eisenmenger's syndrome), the murmur may be absent and S2 can become markedly accentuated and single.


References

  1. Ozpelit E, Akdeniz B, Ozpelit ME, Göldeli O (2014). "Severe tricuspid regurgitation mimicking constrictive pericarditis". Am J Case Rep. 15: 271–4. doi:10.12659/AJCR.890092. PMC 4079647. PMID 24995118.



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