Tricuspid Valve DiseaseTricuspid Valve Disease

Bernardo D. Morantte Jr. M.D.Bernardo D. Morantte Jr. M.D.Dept. of MedicineDept. of Medicine

College of MedicineCollege of MedicinePamantasan Ng Lungsod Ng MaynilaPamantasan Ng Lungsod Ng Maynila

Tricuspid Valve DiseaseTricuspid 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 Pathophysiology of Tricuspid RegurgitationRegurgitation

• 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 RegurgitationEtiology 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

SymptomsSymptoms

• 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 ExaminationPhysical 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

DiagnosticsDiagnostics

• 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

EchocardiographyEchocardiography

• 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 therapyMedical therapy

• Treat the underlying cause• RX• Diuretics• Digoxin• Control of cardiac arrhythmias• SBE prophylaxis*• * Not required if TR is functional in nature

SurgerySurgery

• Indication

For severe tricuspid regurgitation not

improved with medical therapy

• Annuloplasty and implantation of Carpentier ring

Tricuspid StenosisTricuspid Stenosis

• Pathophysiology of Tricuspid Stenosis

The tricuspid valve obstruction causes an increase in RA pressures with progressive RA dilatation

Pathophysiology of TricuspidPathophysiology of TricuspidStenosisStenosis

Right HeartRA

RV

PA

Tricuspid valve

Pulmonic valve

Etiology of Tricuspid stenosisEtiology 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

SymptomsSymptoms

• Easifatigability

• Abdominal swelling

• Peripheral edema

• Exertional syncope

• Other symptoms are related to the associated diseases and anomalies

Physical ExaminationPhysical 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

DiagnosticsDiagnostics

• EKG _ RA hypertrophy

• giant P waves suggest Eibstein

anomaly

• Chest x-ray

• Prominent right heart border

EchocardiograpyEchocardiograpy

• 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 therapyMedical therapy

• RX • Duiretics• Digoxin for control of A-fib• Rheumatic fever prophylaxis• SBE prophylaxis

• Invasive Balloon valvulotomy

Indication for invasive interventionIndication for invasive intervention

• Persistent symptoms despite medical therapy in a patient with valve area of

1.5 cm2 or less

SurgerySurgery

• Open commisurotomy

• Tricuspid valve replacement

• Prognosis: Depends on underlying cause and other associated pathologies