Tricuspid Stenosis

Tricuspid stenosis is a rare obstruction of right ventricular inflow.

Causes: rheumatic disease (nearly always with mitral valve disease, in under 5% of rheumatic cases), carcinoid heart disease, congenital, right atrial myxoma or other tumours, endocarditis, Fabry disease, Whipple disease, methysergide, pacemaker lead induced fibrosis, extrinsic compression.

Severity: mean gradient 5 mmHg or more at heart rate 70 beats per minute, valve area 1.0 cm2 or less, pressure half time over 190 ms.

Consequences: elevated right atrial pressure, systemic venous congestion, low cardiac output, atrial fibrillation.

• Fatigue, abdominal fullness, ascites, hepatomegaly, peripheral oedema, ankle swelling, neck pulsation, symptoms of the coexisting mitral disease.
• Giant a waves in the jugular venous pulse (sinus rhythm), slow y descent, diastolic rumbling murmur at the lower left sternal edge increasing with inspiration (Carvallo sign), tricuspid opening snap.
• Pulmonary congestion is often mild despite severe mitral stenosis, since tricuspid stenosis reduces flow to the left heart.

• Echocardiography: thickened doming leaflets, reduced mobility, mean gradient (Doppler), pressure half time, inferior vena cava dilatation, co existing mitral disease.
• ECG: tall peaked P waves, no right ventricular hypertrophy, atrial fibrillation.
• Chest radiograph: right atrial enlargement without pulmonary artery prominence.
• Cardiac catheterisation seldom needed; use for atrial pressure gradients.
• Investigate carcinoid (urinary 5 HIAA, chromogranin A), tumours (CT, MRI), and endocarditis (blood cultures).

• Medical: sodium restriction, loop diuretics (furosemide 40 to 120 mg), spironolactone 25 to 100 mg for hepatic congestion, rate control in atrial fibrillation, anticoagulation with warfarin (rheumatic atrial fibrillation).
• Rheumatic prophylaxis: benzathine penicillin G 1.2 million units IM every 3 to 4 weeks.
• Intervention for severe tricuspid stenosis with symptoms (usually combined with left sided valve surgery):
  • Percutaneous balloon tricuspid valvuloplasty (rarely used in isolation; risk of regurgitation).
  • Surgical commissurotomy or valve repair; replacement when repair impossible. Bioprosthetic valves are generally preferred because of thrombosis risk with mechanical valves in the tricuspid position.
  • Concurrent surgery during mitral valve surgery.
• Carcinoid heart disease: somatostatin analogue (octreotide LAR 20 to 30 mg every 4 weeks, lanreotide 120 mg every 4 weeks), telotristat; valve replacement of tricuspid and pulmonary valves before right ventricular failure; manage carcinoid crisis perioperatively with octreotide infusion 100 to 500 micrograms/h.
• Endocarditis prophylaxis for prosthetic valves; echocardiographic follow up.