Tricuspid Stenosis

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 ...