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Key Concepts

  • Epidemiology

    • Although as many as 70 percent of Americans may have a small amount of tricuspid regurgitation (TR) on echocardiogram, true disease of the tricuspid valve only affects 0.8 percent of the population. Approximately 8000 surgical procedures are performed for tricuspid disease each year in the United States. The most common manifestation of tricuspid valve disease is functional TR, which occurs secondary to left-sided heart valve disease and is present in approximately 30 percent of patients with severe mitral regurgitation and up to 53 percent of patients undergoing mitral valve surgery. Risk factors for TR include age (OR 1.5/9.9 years; 95 percent CI 1.3–1.7), body mass index (OR 0.7/4.3 kg/m2; 95 percent CI 0.6–0.8), and female gender (OR 1.2; 95 percent CI 1.0–1.6).

  • Pathophysiology

    • In most cases, tricuspid valve disease presents as functional regurgitation secondary to left-sided valvular disease or heart failure (particularly in the setting of pulmonary hypertension). Structural causes of tricuspid valve disease are less common, and include rheumatic heart disease, endocarditis, carcinoid, papillary muscle dysfunction, trauma (often from endomyocardial biopsies or pacemaker lead placement), and congenital anomalies.

  • Clinical features

    • Tricuspid valve disease is often detected incidentally during evaluation for left heart conditions. Signs and symptoms are often consistent with congestive heart failure and can include dyspnea on exertion, orthopnea, jugular venous distention, ascites, and peripheral edema. Advanced disease also can present with hemoptysis and paroxysmal nocturnal dyspnea. Physical examination reveals a pansystolic (TR) or presystolic [tricuspid stenosis (TS)] murmur in the fourth and fifth intercostal spaces at the left sternal border or epigastrium. Hepatojugular reflux, pulsatile liver, and signs of hepatic dysfunction also may be present. Tricuspid endocarditis often presents with pneumonia or manifestations of septic emboli.

  • Diagnostics

    • Electrocardiographic features include peaked P waves or a Q wave in V1 as a result of right atrial volume overload and enlargement. Plain chest radiography may demonstrate cardiomegaly with right-sided chamber enlargement. Doppler and two-dimensional echocardiography confirm the diagnosis, revealing structural abnormalities and measuring pulmonary arterial pressures, degree of stenosis/regurgitation, and right ventricular dysfunction. Cardiac catheterization usually confirms elevated right atrial and ventricular end-diastolic pressures in TR. A diastolic pressure–atrioventricular pressure gradient that increases with respiration is found in patients with significant TS. Tricuspid endocarditis is typically diagnosed in the setting of major criteria that include valvular vegetations and pyrexia; positive blood cultures, septic pulmonary emboli, and a murmur constitute the minor criteria.

  • Treatment

    • Tricuspid valve repair or replacement is indicated for TS and moderate-to-severe TR, usually associated with New York Heart Association class III or IV symptoms. TS is usually treated with commissurotomy.

    • Surgical techniques for TR include bicuspidization, DeVega suture annuloplasty, Carpentier ring annuloplasty, and prosthetic valve replacement.

  • Outcomes

    • Untreated, the 1-year survival in patients with severe, moderate, mild, and absent TR is approximately 60, 70, 90, and 91 percent, respectively. The DeVega suture annuloplasty for TR is associated with a 4 percent operative mortality, a 5 percent recurrence rate, and an actuarial survival rate ...

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