Tricuspid Valve Disease

Tricuspid regurgitation (TR) is commonly present on echocar-diography in the majority of patients and therefore, when mild, is considered a normal variant. Severe TR can occur, however, and can create significant symptoms of right-sided CHF (cor pulmonale) and dyspnea. Isolated TR is most often seen in drug addicts secondary to tricuspid valve endocarditis but can also be caused by carcinoid syndrome, trauma, right ventricular (RV) infarction, and certain congenital anomalies. The most common etiology of TR, however, is annular dilation from RV cavity dilation.

Patients with TR present with various symptoms depending on the etiology of the valvular abnormalities. Typically, dyspnea, right- and left-sided failure, and in the case of endocarditis, fever and night sweats may be present. The right ventricle is generally dilated, and a precordial lift is present. The jugular veins are pulsatile and increased. A systolic murmur is generally heard along the left sternal border that increases with respiration.

Patients with severe TR are treated with diuretics and digitalis to treat the associated right-sided failure. ACE inhibitors are indicated if left ventricular dysfunction is present. Treatment of associated valvular abnormalities is typically indicated, such as severe MR or MS. Tricuspid valve annuloplasty is generally done, particularly when the symptoms are severe and long-standing and secondary to mitral valve disease. Tri-cuspid valve replacement is reserved for those patients with abnormal tricuspid valves not amenable to annuloplasty or tricuspid valve repair.

Tricuspid valve stenosis (TS) is mostly caused by rheumatic heart disease and is typically associated with other valvular involvement. TS can also be caused by the carcinoid syndrome (most frequently causes TR) and certain connective tissue diseases. Secondary causes of TS (e.g., tumors, thrombi) can also precipitate secondary TS. Patients can be dyspneic with activity. Typically, there is an increase in the jugular vein with a large a wave, indicating atrial contraction against a stiff tricuspid valve. TS is usually treated with percutaneous valvular commissurotomy, unless unfeasible. Open commissurotomy is then performed, or valve replacement if the leaflets and subvalvular structures are not reparable. Bioprosthetic valves are typically used, and patients generally start warfarin therapy after tricuspid valve replacement.

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