Tricuspid Valve Disease

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • ECG

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

Imaging Findings

• • 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

• • 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

• • 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

• • 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

Surgery

Indications

• • Mitral valve disease requiring operation

  • Symptomatic disease