MioAtlas
G7: Infections and inflammation

Tricuspid infective endocarditis

Infection of the right tricuspid valvular endocardium (predominantly by Staphylococcus aureus in people who inject drugs, central venous catheter carriers, or long-term vascular access lines).

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Definition

Infection of the right tricuspid valvular endocardium (predominantly by Staphylococcus aureus in people who inject drugs, central venous catheter carriers, or long-term vascular access lines), characterized by the proliferation of bulky septic vegetations on tricuspid leaflets with destruction of cusps or chordae, producing tricuspid regurgitation and recurrent septic pulmonary embolic infarctions/abscesses [C3] [G7-14].

Severity criteria

  • Mild (L): Effective regurgitant orifice area (EROA) < 0.20 cm² (< 20 mm²); Regurgitant volume (RV) < 30 mL/beat; vena contracta width (VC) < 3.0 mm; Color Doppler regurgitant jet area < 5 cm² [V1] [V3].
  • Moderate (M): EROA 0.20–0.39 cm² (20–39 mm²); RV 30–44 mL/beat; vena contracta (VC) 3.0–6.9 mm; Jet area 5–10 cm² [V1] [V3].
  • Severe (G): EROA ≥ 0.40 cm² (≥ 40 mm²); RV ≥ 45 mL/beat; vena contracta (VC) ≥ 7.0 mm; Jet area > 10 cm²; Systolic reversal of retrograde flow in hepatic veins [V1] [V3].
  • Vegetation size criterion in right-sided endocarditis: According to the ESC 2023 guideline [C3, Sección 12.1, Tabla 16], vegetation size > 20 mm with recurrent septic pulmonary emboli constitutes a formal indication for tricuspid valve surgery (repair or replacement).

Findings by layer

Hemodynamics

  • Mean right atrial pressure: Elevated in moderate and severe forms (8–16 mmHg) [V3] [B3].
  • Right atrial v wave: Large-amplitude v wave or fused systolic wave (giant cv wave) due to ventricular ejection into the atrium during systole [V3] [B3].
  • Systemic cardiac output: Generally maintained in early stages, with possible fall if RV volume overload restricts LV filling [V3].

Rhythm

  • Predominant rhythm: Sinus tachycardia associated with bacteremia, fever, and active inflammation [C3] [G7-14].
  • Alternative: Atrial fibrillation or flutter due to right atrial dilation [C3].

ECG

  • Sinus tachycardia; right atrial overload (P pulmonale, tall peaked P wave > 2.5 mm in leads II, III, and aVF) in subacute or chronic forms [E1].

Heart sounds and murmurs

  • Tricuspid holosystolic murmur: Medium-to-high frequency regurgitant murmur at the lower left sternal border (4th–5th parasternal intercostal space) [B1] [G7-14].
  • Rivero-Carvallo sign: Crisp and characteristic increase in murmur intensity during deep inspiration, due to physiological increase in venous return to right-sided chambers [B1] [G7-14].
  • Right-sided third heart sound (RV S3): Present in severe forms in tricuspid area, with inspiratory accentuation [B1].

Arterial pulse

  • Accelerated heart rate, preserved or slightly reduced peripheral pulse volume in sepsis [B4].

Jugular venous pulse

  • Marked jugular venous distention with giant systolic v wave (regurgitant cv wave) and deep, rapid y collapse [B3] [G7-14].
  • Palpable systolic hepatic pulsation in right hypochondrium in severe forms [B3].

Maneuvers

  • Deep inspiration (Rivero-Carvallo): Pathognomonically increases the tricuspid holosystolic murmur [B1].
  • Forced expiration: Decreases the tricuspid murmur (unlike left-sided murmurs) [B1].
  • Release of Valsalva maneuver: The tricuspid murmur recovers immediately (within the first 1–2 beats post-strain) [B1].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Sinus Tachycardia

Also known as: Tricuspid infective endocarditis · Right-sided infective endocarditis · Tricuspid valve endocarditis · Right-sided endocarditis · Tricuspid endocarditis

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [C3] 2023 ESC Guidelines for the management of endocarditis . Eur Heart J (2023) . DOI: 10.1093/eurheartj/ehad193 PubMed: 37622656
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [G7-03] European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) . Europace (2020) . DOI: 10.1093/europace/euz246 PubMed: 31702000
  7. [G7-14] Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis . Clin Infect Dis (2000) . DOI: 10.1086/313664 PubMed: 10671344
  8. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  9. [V3] Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance . J Am Soc Echocardiogr (2017) . DOI: 10.1016/j.echo.2017.01.007 PubMed: 28314623