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  • • Tricuspid valve (TV) has 3 leaflets:

    • 1. Anterior

      2. Posterior

      3. Septal

    • Anterior commonly largest, posterior smallest

    • Papillary muscles often multiple, grouped into 3 (anterior, inferior, septal) and contribute chordae to multiple leaflets

    • Functional tricuspid disease:

    • -Secondary to RV dilation causing enlargement of free-wall tricuspid annulus

      -Reflects RV failure and further worsens RV failure

    • Organic regurgitation: Infective endocarditis

    • Tricuspid stenosis (TS): Rheumatic usually (significant in 5% of patients)

    • Carcinoid involvement of tricuspid valve: Deposits on leaflets

    • RA myxomas rarely cause obstruction of tricuspid orifice

    • TS and tricuspid regurgitation (TR): RA hypertension, systemic venous engorgement, hepatic congestion, edema

    • Can lead to hepatic failure, cardiac cirrhosis, anasarca, and renal failure

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Epidemiology

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  • • Causes of valve disease:

    • -Rheumatic carditis (most common)

      -Valve collagen degeneration

      -Infection

    • Less common causes:

    • -Collagen-vascular disease

      -Tumors

      -Carcinoid

      -Marfan syndrome

    • Valvular heart disease: 89,000 hospital discharges in 1998

    • Etiology of TV disease:

    • -Mitral valve disease

      -Cor pulmonale

      -Primary pulmonary hypertension

      -RV infarction

      -Congenital heart disease

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Symptoms and Signs

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  • TS and TR

    • -Related to degree of systemic venous hypertension

      -Fatigue, weakness; without signs of pulmonary congestion

    TR with mitral valve disease

    • -Pulmonary hypertension

      -RV failure

      -Rapid deterioration

    TS: Prominent a wave if in sinus

    TR: Accentuated jugular v wave

    • Liver enlarged, may be firm and fibrotic

    • Ascites and edema without pulmonary congestion

    • Murmurs similar to mitral valve counterparts; usually located more toward left lower sternal border, less at apex; enhanced by inspiration

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Laboratory Findings

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  • • ECG

    • -In sinus rhythm: tricuspid valve disease suggested if P wave amplitude > 0.25mV on lead II

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Imaging Findings

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  • Chest film: Cardiomegaly with prominent RA shadow, absence of pulmonary congestion

    Echocardiography: Information on anatomy and severity of regurgitation, RV function, etiology

    Cardiac catheterization: Diagnosis and identification of etiology

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  • • The findings may be subtle, and tricuspid disease is often overlooked

    • Distended neck veins or the absence of pulmonary congestion

    • Murmurs may be hard to distinguish

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  • • Cardiac catheterization

    • -TS: Demonstrates diastolic pressure gradient between RA and RV (mean diastolic gradient of 5 mm Hg is significant

      -TR: Prominent v wave by catheterization (ventricularization of atrial pressure)

      -Pulmonary hypertension suggests functional cause; absence indicates organic cause of tricuspid disease

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  • • Rheumatic TS: Commissurotomy or valve replacement (residual gradients tolerated poorly); bioprosthetic valve or allografts preferred for TV due to risk of thromboembolism in low flow right heart

    • Symptomatic carcinoid: Replace valve

    • Tricuspid endocarditis: Many have septic pulmonary emboli; antibiotics, replace valve with allograft (resistant to infection)

    • TR: Mitral valve disease (if present) + tricuspid ring annuloplasty

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Surgery

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Indications

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  • • Mitral valve disease requiring operation

    • Symptomatic disease

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References

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