Pulmonary Hypertension and Tricuspid Valve

[DottyCece]

Can a severe isolated tricuspid valve regurgitation result in pulmonary hypertension?  When I had my first echo a year ago my PA pressures were in the 30s.  Last May my mitral valve was replaced, maize procedure done and PPM implanted as a result of sinus node dysfunction.  I had right heart failure after surgery that has persisted and become worse.  An echo last summer showed severe regurg of TV and PA pressures of 42.  Symptoms are now more severe so a stress echo was done last week.  PA pressures at rest were 48 and with activity 69 and pulse ox drop to 85.  A walking pulse ox went from 98 to 88. IVC and right atrium was very large. I will be having a right heart cath next week to confirm the functional data.  I do understand why PA pressures would increase with MV regurg but since it was not up initially please explain to me why it would be up now with the isolated TV regurg issue.  Physiologically, I just don't understand that. Would a repair of the tricuspid valve fix this problem?  I have seen a surgeon but he has been reluctant to go back in, first surgery was 8 months ago.  I have had reoccuring atrial flutter (cardioverted 5 times in eight months, on amiodarone) with a failed ablation attempt secondary to the nature of the tricuspid valve. So an intraoperative ablation has been proposed if they elect to repair the valve. I am young and healthy for the most part though I did have thyroid cancer with a radical neck and parathyroidectomy which complicates taking diuretics.  In spite of all of this, I continue to work full time though it is becoming more difficult.

[Cleveland Clinic]

Dotty,

The pulmonary hypertension could be due to a number of things, typically isolated tricupid regurgitation does not cause it and tricupid repair gets to be a very difficult question without reviewing all of your data.

Right now you are looking at a very complex procedure...reoperation, tricuspid repair, ablation, etc... and I would recommend you seek a second opinion to confirm any procedures before moving forward.

You can submit your records to the Cleveland Clinic or even set up a visit if you would like.

[jan]

We have talked about this before and now I am really confused.  

"The pulmonary hypertension could be due to a number of things, typically isolated tricupid regurgitation does not cause it.

Ok, it doesn't cause it?  But I have been diag. with mildly elev. pulmonary pressure and was told and have read that is it diag. BY the tricuspid regurgitation.  ???

So how is PH related to TR or vice-versa?

[coffee]

I also have some mild PH with tricuspid regurg. My question is why do the docs always use the resting right vent. systol. pressure instead of measuring it somehow during activity? One is rarely just standing still - when activity resumes, doesn't the artery pressures rise? How would they, in fact, measure pressures upon movement? Yes, I am also confused about being told here that there is no connection between tricuspid regurg and PH.

[Lyn2]

I'm glad I am not the only one confused.  I was told I had mild pulmonary hypertension and it was from the tricuspid regurgitation.  My understanding now is that the tricuspid regurg. allows them to make the pressure measurements.  How do they diagnose pulmonary hypertension without tricuspid regurg.  I find it very confusing, still.
I have moderate to severe tricuspid regurg. and a pacemaker.  Why is repair of the tricuspid valve so different from the others?

[DottyCece]

Dear Dr. J.

Thank you so very much for your answer.  I totally agree with you.  My problem is that costs are prohibitive.  My insurance plan doesn't readily agree to out of plan providers since there are providers in the plan that could theoretically meet my needs.  I do have physician support for this and am working hard to make this happen.  In fact, my primary care provider is strongly encouraging me to visit you folks. I will continue to pursue this.

[DottyCece]

Tricuspid regurgitation is often a result of increased pressure in the pulmonary vessels.  This increased pressure can be caused by mitral valve regurgitation.  So, it didn't make sense to me that once my mitral valve was fixed (and I didn't have elevated pulmonary pressures at that time) that now I would have pulmonary hypertension.  Perhaps there are other factors causing this.  The PA pressures that are obtained by transthoracic echo (and Jan explained it very nicely) do approximate those obtained through a heart catheterization.  With a transthoracic echo, it is not possible to obtain a diastolic or mean pumonary pressure.  

Pulmonary hypertension is not just diagnosed with a tricuspid regurgitation.  There are many tests that can be done and it is like a puzzle, the Dr. must piece together the data and make the diagnosis.  Symptoms include (at least for me they did) peripheral edema, jugular vein distension, fatigue (I could sleep all the time) poor activity tolerance, weight loss (that is a good thing, I think), shortness of breath, and a sensation of heart pounding.  I can always feel when I am retaining more fluid with how my heart "pounds".  It is all so fragile.  I do worry a lot about what my future will be.

[jan]

It's nice to know I wasn't alone.  LOL  

Fred, thanks, that was great!

Now, another thing comes to mind.  I know mild MVP and MR are considered at times to be a normal variant, is it the same with TR?  If so, why would they hang another diagnosis on the TR (elev. pulmonary pressure)?

I read here, back in '99, when all this started that MR can cause TR.  So more confusion. If that is so, I ask again why hang the diag. of PH on it?
What if the TR is just from the MR?

A dr. told me PH wasn't a heart problem, I believe it was the lungs.  So, why is it measured by the heart and is it causing pressure in the heart?

How much do I have to pay for this class? ;o)

Thanks to anybody with any info.  I think all of this is so interesting!

Dotty, I am sorry for the problems you can cont. to have.  Hugs

[horseownr]

I too also thought that pulmonary hypertension was caused from TR. It is very confusing! I do have MR and TR. Does anyone have these symptoms? I get the pounding chest, and pulsating neck, shortness breath but this is the strange one, my legs ache constantly. I  wake up with achy legs especially in my lower legs and go to bed the same way. I have gone to see my Primary for this he says " I dont know what this could be." He did send me for some blood work, esr, and pk and I havent heard anything so Im assuming everything is fine. Any suggestions? It started in Nov. when I got sick and hasnt stopped some days its worse than others. Some days my legs feel like dead weight. I hope everything works out for you with the TR.

[jan]

Hi Fred,

I will try to clarify. Try.  LOL

Ok, first I got that TR doesn't cause PH.  Now moving along and trying to clarify.

So, why would they use something that may be a normal variant and say PH based on it?  It just may be I have a normal variant and no PH, right?  But the cardio writes on his impression of the echo PH.


What if the MR caused the TR (since it can).  Now you have TR, because of just because of the MR, but since you have TR they are saying you have PH.  Does that make sense?


Your class was terrific and if I could give you your fees, I would!  :oD

Thanks so much!

[jan]

Fred,

Ok, now I understand.  Thank you!

He never said it was based on my TR.  I just searched what I could on PH here and elsewhere after I saw it as a new finding on my latest echo.  Under "impressions" it said, "mildly elevated pulmonary hypertension".

At my first appt. with my new primary we were discussing different things, because he was teaching a resident and with my knowledge he thought I was a nurse.  He mentioned the PH and was about to say something about it being related to TR, but I beat him to it. :oP  Ha, but I was a bit confused and neither of us knew it.  LOL

Thank you for your patience and sharing your knowledge with me!!!  Ummmm, can I ask you now just what it all means?  The cardio said they would keep an eye on it with periodic echoes.  (He and my EP have a really good reputation, thankfully. So, I feel I am in good hands).

I know with my dysautonomia my bp fluctuates, but does the PH have any bearing on it?  I only recently started have high normal and high bp here and there.  My last 2 ekgs were abnormal, too.  I was admitted to the hospital for the 1st, because it just so happened I went to the ER with L. upper back, shoulder, neck, and arm pain, so with that combo I was invited to stay.  LOL

Thanks again, Fred. :o)

[jan]

P.S.  I am on a small dose of atenolol and verapamil, so it makes me wonder when I get the higher bp's.