Cardiology >Tricuspid Stenosis

 Background

Tricuspid stenosis (TS) is a narrowing of the tricuspid valve orifice that impedes blood flow from the right atrium (RA) into the right ventricle (RV) during diastole. This results in elevated right atrial pressure, systemic venous congestion, and reduced right ventricular preload. It is usually seen in conjunction with other valvular lesions, especially mitral stenosis.

II) Classification or Types

By Etiology:

• • Rheumatic TS: Most common cause; fibrotic thickening and fusion of valve leaflets and chordae.
  • Congenital TS: Rare; associated with Ebstein anomaly or valvular dysplasia.
  • Carcinoid Syndrome: Serotonin-induced fibrotic plaques on the valve.
  • Prosthetic Valve Dysfunction: Bioprosthetic degeneration or pannus formation.
  • Endomyocardial Fibrosis: Less common in industrialized nations.

By Severity (Based on Echocardiographic Criteria):

III) Epidemiology

• • Sex: More common in females (especially in rheumatic heart disease).

  • Age: Typically presents in adulthood.

  • Geography: Higher prevalence in low- and middle-income countries with endemic rheumatic fever.

  • Comorbidities: Frequently coexists with mitral stenosis and atrial fibrillation.

   Etiology

I) What Causes It

• • Rheumatic Heart Disease (most common)
  • Carcinoid Heart Disease
  • Congenital Abnormalities
  • Infective Endocarditis (especially with IVDU)
  • Pacemaker or ICD Leads (mechanical injury)
  • Bioprosthetic Valve Degeneration

II) Risk Factors

• • History of rheumatic fever

  • Female sex

  • Presence of mitral valve disease

  • Congenital cardiac anomalies

  • Carcinoid tumors (metastatic to liver)

  • Intracardiac devices (leads, prosthetics)

   Clinical Presentation

I) History (Symptoms)

Often overshadowed by coexisting left-sided valvular disease. Symptoms reflect right-sided heart congestion:

• • Fatigue (due to reduced cardiac output)
  • Hepatic congestion: right upper quadrant discomfort
  • Peripheral edema
  • Abdominal distension (ascites)
  • Anorexia or early satiety (from GI congestion)
  • Palpitations (from atrial fibrillation)
  • Symptoms worsen with exercise or pregnancy

II) Physical Exam (Signs)

Vital Signs:

• • May be normal
  • Signs of low cardiac output in advanced disease

Jugular Venous Pressure:

• • Prominent “a” waves (due to increased RA contraction against stenotic valve)
  • Slow “y” descent

Cardiac Exam:

• • Diastolic rumbling murmur at left lower sternal border (best heard with inspiration)
  • Opening snap (rare, softer than mitral)
  • Loud S1 if valve is pliable
  • Hepatomegaly (pulsatile liver)
  • Right-sided S3 or ascites in advanced disease

Peripheral:

• • Peripheral edema
  • Ascites
  • Cool extremities in low-output states

   Differential Diagnosis (DDx)

• • Constrictive pericarditis
  • Right atrial myxoma
  • Tricuspid regurgitation
  • Severe pulmonary hypertension
  • Pulmonary embolism
  • Mitral stenosis (if overlapping symptoms)

   Diagnostic Tests

Initial Tests:

Transthoracic Echocardiogram (TTE):

• • Diagnostic test of choice
  • Measures valve area and gradients
  • Evaluates RA/RV size and pressure
  • Doppler assessment of flow velocity

Transesophageal Echocardiogram (TEE):

• • More sensitive for structural abnormalities or vegetations

Electrocardiogram (ECG):

• • Right atrial enlargement (peaked P waves)
  • Atrial fibrillation
  • Right axis deviation (if pulmonary hypertension)

Chest X-ray:

• • RA enlargement
  • Prominent SVC or azygos vein
  • Hepatic congestion

BNP/NT-proBNP:

• • May be elevated if right heart strain

Cardiac MRI/CT:

• • Helps in anatomic assessment, especially for congenital or carcinoid causes

Right Heart Catheterization:

• • Confirms transvalvular gradient
  • Evaluates pulmonary pressures

   Treatment

I) Medical Management

• • Diuretics: Mainstay for symptom relief (edema, ascites)

  • Salt Restriction: Reduces volume overload

  • Atrial Fibrillation Management: Anticoagulation and rate control

  • Treat Underlying Cause: Carcinoid (octreotide), rheumatic fever prophylaxis

II) Interventional/Surgical

Indications for Intervention:

• • Severe TS with symptoms
  • Severe TS undergoing other valve surgery
  • Right atrial enlargement or decreased exercise tolerance

Surgical Tricuspid Valve Repair or Replacement (TVR):

• • Bioprosthetic valves preferred due to low flow risk of thrombosis
  • Often performed during mitral valve surgery

Percutaneous Balloon Valvotomy:

• • Consider in isolated, pliable rheumatic TS with no regurgitation

   Patient Education, Screening, Vaccines

• • Report worsening edema, abdominal swelling, or fatigue

  • Avoid excess salt intake

  • Adherence to diuretic therapy

  • Rheumatic fever prophylaxis (if indicated)

  • Maintain good dental hygiene to prevent infective endocarditis

Vaccinations:

• • Influenza annually

  • Pneumococcal vaccine

  • COVID-19 vaccine

   Consults/Referrals

• • Cardiology: All patients for diagnosis, monitoring, and intervention planning

  • Cardiothoracic Surgery: If valve replacement indicated

  • Infectious Disease: For endocarditis management

  • Gastroenterology: If significant hepatic congestion

  • Primary Care/Internal Medicine: Comorbidity optimization

   Follow-Up

Echocardiography:

• • Mild TS: every 3–5 years
  • Moderate TS: every 1–2 years
  • Severe TS: every 6–12 months or sooner if symptomatic

Monitor:

• • RA and RV size/function
  • Pulmonary pressures
  • Development of regurgitation or arrhythmia
  • Response to diuretics and volume status

Lifestyle & Risk Factor Management:

• • Optimize blood pressure
  • Manage atrial fibrillation
  • Prevent recurrent rheumatic fever (if relevant)