7th March 2024

Tricuspid Valve

Any disorder involving the tricuspid valve tends to generate pressure/volume overload on the right ventricle and can, over time, affect the right atrium. This can manifest as right heart failure with systemic edema. The murmur is generally heard over the tricuspid area.

Tricuspid Stenosis

Tricuspid stenosis (TS) is usually a late complication of acute rheumatic fever. It is also seen in Group A streptococcal pharyngitis, metastatic carcinoid tumours and IVDU as a complication of infective endocarditis. It rarely occurs in the absence of associated mitral/aortic disease. 

Clinical manifestations

It usually presents with dyspnoea, exercise intolerance, abdominal swelling/ascites, peripheral oedema, atrial fibrillation and hepatomegaly. 

Associated symptoms of carcinoid syndrome, such as episodic facial flushing, watery diarrhoea or bronchoconstriction, may be present. 

Clinical examination shows a murmur similar to that heard with mitral stenosis. There should be a high index of suspicion for TS if other signs of right heart involvement are present. The JVP waveform shows prominent a waves. The murmur increases in intensity with inspiration and squatting. 

Diagnosis

Doppler echocardiography is crucial as the tricuspid valve can appear normal in 2D imaging. The presence of an abnormal appearing tricuspid valve with normal appearing mitral and aortic valves should prompt consideration for carcinoid heart disease and dissuade the clinician from rheumatic heart disease as the aetiology. 

Right atrial enlargement with dilated systemic and hepatic veins is consistent with more severe TS. Biochemically, there may be evidence of hepatic involvement, endocarditis or carcinoid syndrome (increased 24h urinary 5 HIAA).

Management

Congenital disease is usually treated with surgery and preoperative alprostadil. TS, as a result of carcinoid heart disease, is treated with fluid and sodium restriction, loop diuretics and somatostatin analogues along with surgical treatment or balloon dilatation. Endocarditis is treated with antibiotics with or without surgery. 

Tricuspid Regurgitation

Moderate or severe tricuspid regurgitation (TR) is observed in 0.55% of the general population and its prevalence increases with age, affecting about 4% of the patients aged 75 years or more. 

Aetiology

Aetiology is secondary in over 90% of cases, due to pressure and/or volume overload mediated RV dilatation or enlarged right atrium and tricuspid annulus due to chronic AF. 

Cardiac implantable electronic device-lead implantation leads to progressive tricuspid regurgitation in 20-30% of patients. 

Other causes include pulmonary hypertension (e.g. Secondary to COPD), rheumatic heart disease, infective endocarditis, Ebstein’s anomaly and carcinoid syndrome.  

Mild or moderate tricuspid regurgitation without abnormal valve anatomy, ventricular function, or pulmonary artery pressure is not necessarily abnormal but is estimated to be present in over 50% of asymptomatic young adults.

Clinical manifestations

Tricuspid regurgitation usually presents with fatigue, dyspnoea, and lower extremity oedema. Additional complaints may include abdominal distension and early satiety. 

Clinical examination reveals an abnormal and prominent v wave and a left lower parasternal systolic murmur (holosystolic or less than holosystolic, depending on the severity of haemodynamic derangement) which is increased on inspiration (Carvallo’s sign). 

Diagnosis

ECG may show AF, evidence of RV strain or evidence of previous myocardial infarction. An echocardiogram is needed to confirm the diagnosis. In secondary TR, annular dilatation is seen with a raised pulmonary artery pressure. 

Management 

Treatment is focused on managing the underlying cause and regular follow up. Medical management of heart failure and risk factor modification is also advised. Severe disease can be treated with annuloplasty or tricuspid valve replacement. Surgery should be considered for medically refractory right heart failure, imminent or existing atrial fibrillation, or progressive right ventricular dilation and dysfunction.

References

• Tricuspid Stenosis BMJ Best Practice. [Online] https://bestpractice.bmj.com/topics/en-gb/473
• Tricuspid Regurgitation BMJ Best Practice. [Online] https://bestpractice.bmj.com/topics/en-gb/472
• Alec Vahanian et al., ESC/EACTS Scientific Document Group, 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Heart Journal, Volume 43, Issue 7, 14 February 2022, Pages 561–632, https://doi.org/10.1093/eurheartj/ehab395