Tricuspid valve stenosis: causes, symptoms, diagnosis, treatment

Tricuspid stenosis is a narrowing of the tricuspid valve opening that impedes blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms of tricuspid stenosis include a fluttering discomfort in the neck, fatigue, cold skin, and discomfort in the right upper quadrant of the abdomen. Jugular venous pulsation is visible, and a presystolic murmur is often heard in the fourth intercostal space on the left at the sternal border, which increases with inspiration. Diagnosis is made by echocardiography. Tricuspid stenosis is usually benign, so no specific therapy is prescribed, although surgery may be effective in symptomatic patients.

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What causes tricuspid stenosis?

Tricuspid stenosis is almost always a consequence of rheumatic fever. In most cases, TR is also present, as in mitral valve disease (usually mitral stenosis). Rare causes of tricuspid stenosis include SLE, carcinoid syndrome, right atrial (RA) myxoma, congenital pathology, primary or metastatic tumor, and localized constrictive pericarditis. The right atrium becomes hypertrophied and distended, heart failure develops as a complication of right heart disease, but without right ventricular dysfunction. The latter remains insufficiently filled and small. Sometimes atrial fibrillation occurs.

Symptoms of Tricuspid Stenosis

Symptoms of severe tricuspid stenosis include throbbing neck discomfort (due to a giant jugular pulse wave), fatigue, cold skin (due to low cardiac output), and right upper quadrant abdominal discomfort (due to an enlarged liver).

The first visible sign is a giant, finely serrated a wave with a gradual decrease in y in the jugular veins. As atrial fibrillation develops, the v wave becomes noticeable in the jugular pulse. Swelling of the jugular veins may be detected, increasing with inspiration (Kussmaul's symptom). The face may acquire a dark color, and the veins of the scalp may dilate when the patient lies down (the "flushing" symptom). Immediately before systole, liver pulsation may be felt. Peripheral edema often occurs.

On auscultation, tricuspid stenosis may produce a soft opening sound. Sometimes a mid-diastolic click is heard. Tricuspid stenosis is characterized by a short, scraping, crescendo-decrescendo presystolic murmur that is heard best with a stethoscope with the diaphragm in the fourth or fifth intercostal space to the right of the sternum or in the epigastric region when the patient is sitting, leaning forward (bringing the heart closer to the chest wall) or lying on the right side (increasing flow through the valve). The murmur becomes louder and longer with maneuvers that increase venous inflow (eg, exercise, inspiration, leg raises, Müller maneuver) and softer and shorter with maneuvers that decrease venous inflow (upright position, Valsalva maneuver).

Signs of tricuspid stenosis are often combined with symptoms of mitral stenosis and are therefore masked by the manifestations of the latter. Murmurs can also be distinguished clinically.

Diagnosis of tricuspid valve stenosis

A preliminary diagnosis is made based on the history and physical examination and is confirmed by Doppler echocardiography, which reveals a tricuspid pressure gradient >2 mmHg with high-velocity turbulent flow and delayed atrial filling. Two-dimensional echocardiography may show right atrial enlargement. An ECG and chest radiograph are often obtained. ECG findings may show right atrial enlargement out of proportion to right ventricular hypertrophy and tall, peaked P waves in the inferior leads and V1. Chest radiograph may show a dilated superior vena cava and right atrial enlargement, visible as a widened right cardiac border. Liver enzymes may be elevated due to liver congestion.

Differences in murmurs in tricuspid and mitral valve stenosis

Characteristic	Tricuspid	Mitral
Character	Scraping	Rumbling, high-pitched
Duration	Short	Long
Time of appearance	Begins in early diastole and does not increase until S	Increases during diastole
Causes of increased noise	Inhale	Physical activity
The best place to listen	At the bottom of the sternum on the right and left	The apex of the heart when the patient lies on the left side

Cardiac catheterization is rarely indicated for tricuspid stenosis. If catheterization is indicated (e.g., to evaluate coronary anatomy), the examination may reveal elevated RA pressure with a slow decline in early diastole and a diastolic pressure gradient across the tricuspid valve.

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Treatment of tricuspid valve stenosis

Indications for treatment are limited. In all symptomatic patients, treatment should include a low-salt diet, diuretics, and ACE inhibitors. Patients with a valvular pressure gradient of approximately 3 mm Hg and a valve area < 1.5 cm ² may be treated surgically. Treatment options include balloon valvotomy and, in patients with unsatisfactory results who are able to tolerate surgery, open valve repair or replacement. Comparative results have not been studied. Correction of tricuspid stenosis without treatment of coexisting mitral stenosis may precipitate left ventricular heart failure.