In a patient with pulmonary hypertension and signs of right-sided heart involvement, a systolic murmur is heard at the right sternal border with a prominent jugular venous pulse. What is the most likely diagnosis?

• A. Mitral Insufficiency
• B. Tricuspid Insufficiency
• C. Hepatic Vein Thrombosis
• D. Aneurysm of the Thoracic Aorta

Answer: (B)

When the right side of the heart is under strain from pulmonary hypertension, the tricuspid valve often dilates, leading to regurgitation of blood back into the right atrium during systole. This creates a systolic murmur that is commonly heard along the lower sternal border and is closely associated with signs of right-sided congestion, such as a prominent jugular venous pulse with marked v waves from the regurgitant flow. In this scenario, the combination of pulmonary hypertension, right-sided involvement, and a systolic murmur compatible with tricuspid valve incompetence points to tricuspid insufficiency as the most likely diagnosis.

The other options don’t fit as well: a mitral valve murmur typically sounds best at the apex and radiates to the axilla, not along the sternum or with prominent JVP from right-sided failure; hepatic vein thrombosis presents with hepatomegaly, ascites, and abdominal symptoms rather than a systolic murmur tied to right-sided valvular disease; an aneurysm of the thoracic aorta would produce different cardiovascular signs and a murmur related to aortic pathology rather than a right-sided regurgitant murmur with elevated JVP.