Tricuspid stenosis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Tricuspid valve stenosis is a valvular heart disease which results in the 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.
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. Tricuspid stenosis takes years to develop, with the exception of congenital causes or active infective endocarditis.
Pathophysiology
Tricuspid stenosis is characterized by structural changes in the tricuspid valve. The pathophysiology of tricuspid valve depends on the underlying etiology. In rheumatic heart disease, the most common cause of tricuspid stenosis, there is diffuse thickening of the leaflets and chordae tendinae as well as fusion of the commissures.[1]
Epidemiology and Demographics
Tricuspid stenosis (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.[2] 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.
Natural History, Complications, and Prognosis
Tricuspid stenosis is rarely an isolated disease, it is usually associated with existing mitral valve abnormality and/or tricuspid regurgitation. Complications of tricuspid stenosis include heart failure, liver failure, and stroke.[3]
Causes
The most common cause of tricuspid stenosis is rheumatic heart disease. Other causes of tricuspid stenosis include carcinoid syndrome, congenital abnormalities, endocarditis, lupus, and mechanical obstruction by a tumor.[4][1]
Differential Diagnosis
The differential diagnosis of tricuspid stenosis includes other valvular abnormalities and diseases that can cause a similar clinical presentation, such as tricuspid atresia, pericarditis, and atrial myxoma.
Diagnosis
History and Symptoms
Tricuspid stenosis is mostly associated with mitral valve abnormalities. Common symptoms include dyspnea, peripheral edema, and fatigue.
Physical Examination
Normally, tricuspid stenosis co-exists with mitral stenosis, thus depending on the severity of mitral valve pathology, symptoms differ. Since these two diseases often coexist, the diagnosis of tricuspid stenosis may be missed. Patients can lay flat without any symptoms in absence of serious mitral valve pathology and thus not present with any signs of dyspnea. Characteristic findings of tricuspid stenosis include opening snap and a diastolic rumbling murmur that is localized to the the right sternal border and that increases with inspiration.
Electrocardiogram
The electrocardiogram of patients with tricuspid stenosis can demonstrate a sinus rhythm with or without signs of right atrial hypertrophy can be present.[3] Patients with tricuspid stenosis 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 tricuspid stenosis may be significant for a pronounced right atrial enlargement. The heart size can range from a normally sized heart to cardiomegaly.
Echocardiography
Transthoracic echocardiography (TTE) should be performed among patients with suspected tricuspid stenosis (TS) to confirm the diagnosis, determine the etiology, and establish the baseline severity. TTE commonly reveals findings of associated with other valvular diseases, such as tricuspid regurgitation and/or mitral stenosis. TS is mainly characterized by an elevated transvalvular gradient.[4]
Cardiac MRI
While echocardiography remains the diagnostic imaging modality of choice, cardiac MRI is useful to evaluate tricuspid stenosis 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 tricuspid stenosis 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.[5] 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 tricuspid stenosis complicated by systemic and pulmonary congestion. Patients with tricuspid stenosis should recieve medical therapy for left heart failure, and/or pulmonary hypertension in case they are present.[6]
Surgery
Surgical tricuspid valve replacement in tricuspid stenosis (TS) is recommended among patients undergoing surgical intervention for left valvular disease as well as among patients with severe symptomatic isolated TS.[6]
References
- ↑ 1.0 1.1 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.
- ↑ Goswami KC, Rao MB, Dev V, Shrivastava S (1999). "Juvenile tricuspid stenosis and rheumatic tricuspid valve disease: an echocardiographic study". Int J Cardiol. 72 (1): 83–6. PMID 10636636.
- ↑ 3.0 3.1 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.
- ↑ 4.0 4.1 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.
- ↑ 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.
- ↑ 6.0 6.1 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.