7th March 2024

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.