Tricuspid stenosis overview: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
The differential diagnosis of [[TS]] includes other valvular abnormalities and diseases | The differential diagnosis of [[TS]] includes other valvular abnormalities such as aortic regurgitation due to the similarity in the type of murmur, and diseases resulting in similar clinical presentation of elevated systemic venous pressures such as [[constrictive pericarditis]], right ventricular dysfunction, restrictive cardiomyopathy, [[atrial myxoma]], etc. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
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===Physical Examination=== | ===Physical Examination=== | ||
Tricuspid stenosis often co-exists with [[mitral stenosis]], thus depending on the severity of mitral valve pathology, symptoms differ. The diagnosis of TS may also be missed when they coexist. Patients can lay flat without any symptoms in the absence of serious mitral valve pathology and thus, not present with any signs of [[dyspnea]]. Characteristic findings of TS include an opening snap and a diastolic rumbling murmur that is localized to the lower left sternal border at the fourth intercostal space and it increases with inspiration. | |||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
The [[electrocardiogram]] of patients with TS can demonstrate a sinus rhythm with or without | The [[electrocardiogram]] of patients with TS can demonstrate a sinus rhythm with or without right atrial hypertrophy.<ref name="pmid15786615">{{cite journal| author=Diaof M, Ba SA, Kane A, Sarr M, Diop IB, Diouf SM| title=[Tricuspid valve stenosis. A prospective study of 35 cases]. | journal=Dakar Med | year= 2004 | volume= 49 | issue= 2 | pages= 96-100 | pmid=15786615 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15786615 }} </ref> Patients with TS experience frequent arrhythmias, particularly [[atrial flutter]] and/or [[atrial fibrillation]] due to the enlargement of the [[right atrium]]. | ||
===Chest X-Ray=== | ===Chest X-Ray=== | ||
The chest X-ray in a patient with TS may be significant for a pronounced right atrial enlargement. The heart size can range from a | The chest X-ray in a patient with TS may be significant for a pronounced right atrial enlargement. The heart size can range from a normal-sized heart to [[cardiomegaly]]. | ||
===Echocardiography=== | ===Echocardiography=== | ||
[[Transthoracic echocardiography]] ([[TTE]]) should be performed among patients with suspected TS to confirm the diagnosis, determine the etiology, and establish the baseline severity. TTE commonly reveals findings | [[Transthoracic echocardiography]] ([[TTE]]) should be performed among patients with suspected TS to confirm the diagnosis, determine the etiology, and establish the baseline severity. TTE commonly reveals findings associated with other valvular diseases, such as [[tricuspid regurgitation]] and/or [[mitral stenosis]]. TS is mainly characterized by an elevated transvalvular gradient.<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref> | ||
===Cardiac MRI=== | ===Cardiac MRI=== | ||
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==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Medical therapy with [[diuretics]] and sodium restriction is the mainstay of treatment among patients with TS complicated by systemic and pulmonary congestion. Patients with TS should | Medical therapy with [[diuretics]] and sodium restriction is the mainstay of treatment among patients with TS complicated by systemic and pulmonary congestion. Patients with TS should receive medical therapy for [[left heart failure]], and/or [[pulmonary hypertension]] in case they are present.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref> | ||
===Surgery=== | ===Surgery=== | ||
Revision as of 21:04, 8 December 2016
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Tricuspid stenosis Microchapters |
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Tricuspid stenosis overview On the Web |
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Risk calculators and risk factors for Tricuspid stenosis overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
Tricuspid stenosis (TS) is a type of valvular heart disease where there is narrowing of the orifice of the tricuspid valve of the heart. This tricuspid valve dysfunction may be a result of morphological alterations in the valve or from functional deviations from the norm of the myocardium. It is almost always caused by rheumatic fever and is generally accompanied by mitral stenosis and aortic valve involvement.[1] A majority of stenotic tricuspid valves are associated with evidence of regurgiation that has been clinically documented through a physicial examination (murmur), echocardiogram, or angiogram. Stenotic tricuspid valves are also anatomically abnormal, which can be caused by a limited number of conditions. TS takes years to develop, with the exception of congenital causes or active infective endocarditis.
Pathophysiology
TS is characterized by structural changes in the tricuspid valve. The pathophysiology of the tricuspid valve depends on the underlying etiology. In rheumatic heart disease which is the most common cause of TS, there is diffuse scarring and fibrosis of the valve leaflets, fusion of the commissures, and shortening of the chordae tendineae as a result of inflammation.[2] These abnormalities limit leaflet mobility and reduce the size of the tricuspid orifice, thereby obstructing right ventricular filling.
Causes
The most common cause of TS is rheumatic heart disease. Other causes of TS include carcinoid syndrome, congenital abnormalities, endocarditis, lupus, and mechanical obstruction by a tumor.[3][2]
Differential Diagnosis
The differential diagnosis of TS includes other valvular abnormalities such as aortic regurgitation due to the similarity in the type of murmur, and diseases resulting in similar clinical presentation of elevated systemic venous pressures such as constrictive pericarditis, right ventricular dysfunction, restrictive cardiomyopathy, atrial myxoma, etc.
Epidemiology and Demographics
TS is the least common valvular disease. TS is rarely an isolated disease, it is mostly associated with mitral valve abnormalities and/or concomitant tricuspid regurgitation. Approximately 8% of patients with rheumatic heart disease develop isolated TS, while up to 50% develop tricuspid regurgitation and TS.[4] The prevalence of TS is lower in developed countries compared to developing countries due to the low prevalence of rheumatic heart disease, the most common cause of TS.
Risk Factors
One of the most recognized risk factors of TS is rheumatic fever.
Natural History, Complications, and Prognosis
TS is rarely an isolated disease, it is usually associated with existing mitral valve abnormality and/or tricuspid regurgitation. Complications of TS include heart failure, liver failure, and stroke.[5]
Diagnosis
History and Symptoms
TS is mostly associated with mitral valve abnormalities. Common symptoms include dyspnea, peripheral edema, and fatigue.
Physical Examination
Tricuspid stenosis often co-exists with mitral stenosis, thus depending on the severity of mitral valve pathology, symptoms differ. The diagnosis of TS may also be missed when they coexist. Patients can lay flat without any symptoms in the absence of serious mitral valve pathology and thus, not present with any signs of dyspnea. Characteristic findings of TS include an opening snap and a diastolic rumbling murmur that is localized to the lower left sternal border at the fourth intercostal space and it increases with inspiration.
Electrocardiogram
The electrocardiogram of patients with TS can demonstrate a sinus rhythm with or without right atrial hypertrophy.[5] Patients with TS experience frequent arrhythmias, particularly atrial flutter and/or atrial fibrillation due to the enlargement of the right atrium.
Chest X-Ray
The chest X-ray in a patient with TS may be significant for a pronounced right atrial enlargement. The heart size can range from a normal-sized heart to cardiomegaly.
Echocardiography
Transthoracic echocardiography (TTE) should be performed among patients with suspected TS to confirm the diagnosis, determine the etiology, and establish the baseline severity. TTE commonly reveals findings associated with other valvular diseases, such as tricuspid regurgitation and/or mitral stenosis. TS is mainly characterized by an elevated transvalvular gradient.[3]
Cardiac MRI
While echocardiography remains the diagnostic imaging modality of choice, cardiac MRI is useful to evaluate TS when the results of the echocardiography are insufficient.
Cardiac Catheterization
While echocardiography remains the diagnostic imaging modality of choice, cardiac catheterization is useful to evaluate TS when the results of the non-invasive testing are insufficient, particularly among patients who are being evaluated for other conditions such as mitral stenosis and pulmonary hypertension.[6] In the older pre-surgery population, cardiac catheterization may be necessary in order to assess concomitant artery disease.
Treatment
Medical Therapy
Medical therapy with diuretics and sodium restriction is the mainstay of treatment among patients with TS complicated by systemic and pulmonary congestion. Patients with TS should receive medical therapy for left heart failure, and/or pulmonary hypertension in case they are present.[7]
Surgery
Surgical tricuspid valve replacement in TS is recommended among patients undergoing surgical intervention for left valvular disease as well as among patients with severe symptomatic isolated TS.[7]
References
- ↑ Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA (1998). "Long-term follow-up of patients with severe rheumatic tricuspid stenosis". Am Heart J. 136 (1): 103–8. PMID 9665226.
- ↑ 2.0 2.1 Waller BF, Howard J, Fess S (1995). "Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part I." Clin Cardiol. 18 (2): 97–102. PMID 7720297.
- ↑ 3.0 3.1 Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP; et al. (2009). "Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice". Eur J Echocardiogr. 10 (1): 1–25. doi:10.1093/ejechocard/jen303. PMID 19065003.
- ↑ Goswami KC, Rao MB, Dev V, Shrivastava S (1999). "Juvenile TS and rheumatic tricuspid valve disease: an echocardiographic study". Int J Cardiol. 72 (1): 83–6. PMID 10636636.
- ↑ 5.0 5.1 Diaof M, Ba SA, Kane A, Sarr M, Diop IB, Diouf SM (2004). "[Tricuspid valve stenosis. A prospective study of 35 cases]". Dakar Med. 49 (2): 96–100. PMID 15786615.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.
- ↑ 7.0 7.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.