Tricuspid Stenosis

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

• The incidence of tricuspid stenosis after tricuspid valve replacement increases considerably 8 years post surgery

• 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)

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

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

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 tricuspid prosthetic valve stenosis

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