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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Prominent a wave and reduced y descent in jugular venous pulse

  • Diastolic murmur at left lower sternal border that increases with inspiration

  • Characteristic Doppler echocardiographic findings including thickened valve leaflets, right atrial enlargement, and increased diastolic flow velocity across the valve

GENERAL CONSIDERATIONS

  • An uncommon lesion, tricuspid stenosis almost always is due to rheumatic heart disease and accompanies mitral stenosis

  • Occasionally congenital in origin

  • Infrequently the predominant lesion in Ebstein’s anomaly

  • Rarely, carcinoid can cause tricuspid stenosis along with pulmonic stenosis

  • Another unusual cause is methysergide therapy

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Abdominal distention, jaundice, and wasting

  • Fatigue

  • Symptoms of the underlying or associated disease, such as exertional dyspnea with mitral stenosis

PHYSICAL EXAM FINDINGS

  • Elevated jugular venous pulse with a slow y descent and a prominent a wave

  • Auscultation:

    • – Tricuspid opening snap and diastolic rumble along the lower left sternal border that increases with inspiration

    • – May be difficult to distinguish from associated mitral stenosis

  • Ascites and edema

DIFFERENTIAL DIAGNOSIS

  • Mitral stenosis

  • Right atrial myxoma

  • Metastatic tumors to right heart

  • Pulmonary hypertension with right heart failure

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Liver function tests: abnormal

ELECTROCARDIOGRAPHY

  • ECG findings:

    • – Right atrial enlargement without right ventricular hypertrophy

    • – Atrial fibrillation common

IMAGING STUDIES

  • Chest x-ray:

    • – Right atrial enlargement

    • – Reduced pulmonary vasculature

    • – Pleural effusions

  • Two-dimensional echocardiography:

    • – Thickened, domed tricuspid valve with restricted motion

    • – Dilated right atrium

    • – Doppler echocardiography estimates the pressure gradient across the valve, which determines severity of obstruction

    • – The normal tricuspid inflow velocity is < 1 m/s, and the mean gradient is < 2 mm Hg

    • – Severe tricuspid stenosis is defined as a mean gradient ≥ 7 mm Hg and a pressure half-time > 190 ms

DIAGNOSTIC PROCEDURES

  • Cardiac catheterization:

    • – Elevated right atrial pressure with a dominant a wave and a slow y descent

    • – Diastolic gradient between right atrium and ventricle—often small—so calculation of tricuspid valve area is unreliable

TREATMENT

CARDIOLOGY REFERRAL

  • Right heart failure

  • Symptoms due to underlying or accompanying disease

HOSPITALIZATION CRITERIA

  • Heart failure

  • Atrial fibrillation

MEDICATIONS

  • Treatment of underlying or associated diseases such as carcinoid

  • Diuretics for right heart failure

THERAPEUTIC PROCEDURES

  • Percutaneous balloon valvuloplasty feasible in some cases

  • Percutaneous valve in valve replacement can be done for a failed tricuspid bioprosthesis

SURGERY

  • Repair or replacement, usually with a bioprosthetic valve

MONITORING

  • ECG ...

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