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Key Features

Essentials of Diagnosis

  • Female predominance

  • Right heart failure after rheumatic heart disease, tricuspid valve repair or replacement, and carcinoid disease are the most common causes in the United States

  • Elevated jugular venous pulsations (JVP) with prominent a wave

  • Echocardiography/Doppler is diagnostic; mean valve gradient > 5 mm Hg or tricuspid valve area < 1.0 cm2 indicates severe tricuspid stenosis

General Considerations

  • Rare; affects < 1% of the population in developed countries and < 3% worldwide

  • Is frequently accompanied by tricuspid regurgitation

  • Combination should be suspected when "right heart failure" appears in mitral valve disease or postoperatively after tricuspid valve repair or replacement

  • Congenital form may be seen

  • Multiple pacemaker leads can create right ventricular (RV) inflow obstruction at the tricuspid valve (case reports)

Clinical Findings

Symptoms and Signs

  • Right heart failure with hepatomegaly, ascites, and dependent edema

  • In sinus rhythm, a giant a wave in the JVP, which is elevated

  • Typical diastolic rumble along the lower left sternal border (mimics mitral stenosis, although it increases with inspiration)

  • In sinus rhythm, a presystolic liver pulsation may be found

  • Should be considered when patients exhibit signs of carcinoid syndrome

Diagnosis

Imaging Studies

  • Chest radiograph findings

    • Marked cardiomegaly with a normal pulmonary artery (PA) size

    • Dilated superior vena cava (SVC) and azygous vein

Diagnostic Studies

  • In the absence of atrial fibrillation, the ECG reveals right atrial (RA) enlargement

  • The normal tricuspid valve area is 10 cm2, so significant stenosis must be present to produce a gradient

  • A mean diastolic pressure gradient > 5 mm Hg is considered hemodynamically significant, although even a 2 mm Hg gradient is abnormal

Treatment

Medications

  • Diuretics are mainstay in reducing the fluid congestion

  • Torsemide and bumetanide may have an advantage over furosemide and other loop diuretics when there is considerable bowel edema because they are better absorbed from the gut

  • Aldosterone inhibitors (eg, spironolactone) also help, particularly if there is liver engorgement or ascites

Surgery

  • Neither surgical nor percutaneous valvuloplasty is particularly effective, since residual tricuspid regurgitation is common

  • Tricuspid valve replacement is the preferred surgical approach

    • Bioprosthetic tricuspid valves are almost always used

    • Mechanical tricuspid valve replacement is now rarely done

  • Percutaneous transcatheter valve replacement (stented valve) has been used in degenerative prosthetic valve stenosis

Outcome

Prognosis

  • May be progressive, eventually causing severe right-sided heart failure

When to Refer

  • All patients with any evidence for tricuspid stenosis on an echocardiogram should be seen and followed by a cardiologist to assess when intervention may be required

References

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