ESSENTIALS OF DIAGNOSIS
History of rheumatic heart disease most likely. Carcinoid disease and prosthetic valve degeneration are the most common etiologies in the United States.
Elevated JVP with prominent a wave.
Right heart failure after tricuspid surgery or in rheumatic disease or carcinoid syndrome.
Echocardiography/Doppler is diagnostic; mean valve gradient > 5 mm Hg or tricuspid valve area < 1.0 cm2 indicates severe tricuspid stenosis.
Tricuspid stenosis is rare, affecting less than 1% of the population in developed countries and less than 3% worldwide. Native valve tricuspid valve stenosis is usually rheumatic in origin. In the United States, tricuspid stenosis is more commonly due to prior tricuspid valve repair or replacement or to the carcinoid syndrome. The incidence of tricuspid stenosis after tricuspid valve replacement increases considerably after 8 years post surgery. Tricuspid regurgitation frequently accompanies the lesion. It should be suspected when right heart failure appears in the course of mitral valve disease or in the postoperative period after tricuspid valve repair or replacement. Congenital forms of tricuspid stenosis may also be rarely observed, as have case reports of multiple pacemaker leads creating RV inflow obstruction at the tricuspid valve.
Tricuspid stenosis is characterized by right heart failure with hepatomegaly, ascites, and dependent edema. In sinus rhythm, a giant a wave is seen in the JVP, which is also elevated (see Table 10–1). The typical diastolic rumble along the lower left sternal border mimics mitral stenosis, though in tricuspid stenosis the rumble increases with inspiration. In sinus rhythm, a presystolic liver pulsation may be found. It should be considered when patients exhibit signs of carcinoid syndrome.
In the absence of atrial fibrillation, the ECG reveals RA enlargement. The chest radiograph may show marked cardiomegaly with a normal PA size. A dilated superior vena cava and azygous vein may be evident.
The normal valve area of the tricuspid valve is 10 cm2, so significant stenosis must be present to produce a gradient. Hemodynamically, a mean diastolic pressure gradient greater than 5 mm Hg is considered significant, although even a 2 mm Hg gradient can be considered abnormal. This can be demonstrated by echocardiography or cardiac catheterization. The 2017 update of the 2014 AHA/ACC guidelines suggests a tricuspid valve area of less than 1.0 cm2 and a pressure half-time longer than 190 msec should be defined as significant because the gradient may vary depending on the heart rate.
Tricuspid stenosis may be progressive, eventually causing severe right-sided heart failure. Initial therapy is directed at reducing the fluid congestion, with diuretics the mainstay (see Treatment, Heart Failure). When there is considerable bowel edema, torsemide or bumetanide may ...