Tricuspid Valve Disease

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 • • • •

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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