Tricuspid Regurgitation (TR)

Also called tricuspid insufficiency, it’s detected as an early or pansystolic murmur heard best at the tricuspid area, i.e. lower left sternal border (LLSB).  It’s often an obvious “whoosh,” but early TR can be a high-pitched squeak overshadowed by mitral S1 & S2.

However, systolic murmurs in the LLSB area are most commonly functional (or physiologic); we ignore them, don’t even consider an echo.  The KEY: functional murmurs are always mid-systolic.  TR is early systolic.

Early Systolic murmurs are contiguous with the first heart sound — you don’t hear S1.  It’s melted into the murmur.  If there’s even the tiniest bit of space (silence) between S1 & the murmur, it’s mid-systolic.  For me at least, it’s easier to conceptualize visually:


In terms of finding murmurs in general, a PEARL from a brilliant internist I knew: don’t listen for murmurs, rather, listen for silence.  Auscultate a given area for S1, then S2.  When you’re comfortable you hear them, concentrate hard on the space in between (systole).  convince youself there’s silence.  If not, there’s a murmur.

Then determine that you hear both S1 & S2 as well as the murmur.  That makes it “mid-systolic.”  At the LLSB (or even just LSB), it’s functional.