Tricuspid Valve Disease

Bernardo D. Morantte Jr. M.D.

Dept. of Medicine
College of Medicine
Pamantasan Ng Lungsod Ng Maynila
 Tricuspid Valve Disease
• Tricuspid regurgitation is the back flow of
blood from RV to RA during systole.

• Tricuspid stenosis is the narrowing of the

valve orifice with obstruction in the
diastolic blood flow from RA to RV.
 Pathophysiology of Tricuspid
Regurgitation
• Progressive RV dilatation causes the TV
annulus to dilate. The valve leaflets do not
coaptate completely with development of
regurgitant blood flow to the RA

• Progressive RA dilatation occurs

 Etiology of Tricuspid Regurgitation
• Most commonly secondary to pulmonary hypertension of whatever
etiology such as COPD, pulmonary emboli, left sided valvular
disease_ MS, MR, AS, AR
• Dilated and restrictive cardiomyopathy
• Bacterial endocarditis
• Congenital
Pulmonic stenosis
Eibstein anomaly
Arrythmogenic right ventricular dysplasia
• RV infarction
• Trauma
• Functional
Congenital or artificial AV fistulas (dialysis patients)
Pacemakers
 Symptoms
• RUQ tenderness due to hepatomegaly
• Abdominal swelling
• Peripheral edema

• Symptoms related to chronic lung disease and other

associated valvular disease:
• dyspnea , orthopnea / PND
• cough and wheezing
• easifatigability
• syncope due to malignant ventricular
• arrhythmias in arrythmogenic RV dysplasia
 Physical Examination
• Key Findings: Gr II-IV blowing systolic murmur
at the lower sternal region which increases on
inspiration

• S1 , S2 , right sided S3, S4

• Sternal lifting or substernal pulsation
• Jugular venous distention with large V waves
• Pulsatile enlarge liver
• Ascites
• Peripheral edema
 Diagnostics
• EKG _ RAH and RVH
• giant P waves suggest Eibstein
anomaly
Ventricular tachycardia (VT) in RV
dysplasia
• Holter monitoring if recurrent syncope is occurring

• Chest x-ray
Prominent right heart border
Obliteration of retrosternal space in the
left lateral view
 Echocardiography
• Key Finding: the presence of regurgitant
• jet in the RA by doppler and
• elevated RA pressures.
• RV and RA dilatation
• Prolapse of the tricuspid valve
• Bacterial vegetations
• Giant anterior leaflet and ventricularization of the
RA confirms the diagnosis of Eibstein anomaly
 Medical therapy
• Treat the underlying cause
• RX
• Diuretics
• Digoxin
• Control of cardiac arrhythmias
• SBE prophylaxis*
• * Not required if TR is functional in nature
 Surgery
• Indication
For severe tricuspid regurgitation not
improved with medical therapy

• Annuloplasty and implantation of

Carpentier ring
 Tricuspid Stenosis
• Pathophysiology of Tricuspid Stenosis

The tricuspid valve obstruction causes an

increase in RA pressures with progressive
RA dilatation
 Pathophysiology of Tricuspid
Stenosis
Right Heart
RA

PA
Pulmonic
valve

Tricuspid valve
RV
 Etiology of Tricuspid stenosis
• Part of a multivalvular involvement in rheumatic heart
disease
• Carcinoid syndrome
• Congenital _ Eibstein anomaly
• Connective tissue disease such as SLE
• Methysergide therapy
• Antiphospholid syndrome
• Others:
• Whipples disease
• Fabry’s disease
• Endocardial fibroelastosis
 Symptoms
• Easifatigability
• Abdominal swelling
• Peripheral edema
• Exertional syncope
• Other symptoms are related to the
associated diseases and anomalies
 Physical Examination
• Key finding: the presence of long
• diastolic murmur in the lower sternal
• or subxyphoid region which increases
on inspiration. Right sided opening
snap (OS) may be present. There is
presystolic accentuation if the rhythm
is sinus.
• S1 is increased
• Signs of right heart failure
• jugular venous distention with A wave
• hepatomegaly
• peripheral edema
 Diagnostics
• EKG _ RA hypertrophy
• giant P waves suggest Eibstein
anomaly
• Chest x-ray
• Prominent right heart border
 Echocardiograpy
• Key finding: Stiff and deformed tricuspid

leaflets with increased diastolic

velocities across the tricuspid
valve and turbulence in the
doppler flow signal
• Giant anterior leaflet of the tricuspid valve
and ventricularization of RA suggest
Eibstein anomaly
 Medical therapy
• RX
• Duiretics
• Digoxin for control of A-fib
• Rheumatic fever prophylaxis
• SBE prophylaxis

• Invasive
Balloon valvulotomy
 Indication for invasive intervention

• Persistent symptoms despite medical

therapy in a patient with valve area of
1.5 cm2 or less
 Surgery
• Open commisurotomy

• Tricuspid valve replacement

• Prognosis: Depends on underlying cause

and other associated pathologies