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Tricuspid Stenosis

Tricuspid valve stenosis is a condition involving a restriction of the orifice of the tricuspid valve, which correspondingly leads to diminished blood flow from the right atrium to the right ventricle.


Presentation

Tricuspid valve stenosis is rarely a condition solely responsible for the symptoms reported by affected patients. Isolated tricuspid valve stenosis and congenital type of the disorder are very rare [1]. Symptoms accompanying tricuspid valve stenosis are elicited by the condition in question, and also by mitral and aortic valve diseases, as these pathologies tend to be closely linked together [2].

For these reasons, symptomatology separately caused by tricuspid valve stenosis is difficult to be defined precisely. Nevertheless, patients who are diagnosed with the condition tend to present with the following symptoms [3] [4]:

Fatigue
  • Symptoms of tricuspid regurgitation may include decreased urination, fatigue, swelling in the abdomen, feet or ankles and abnormal pulsing experienced in the neck veins.[emoryhealthcare.org]
  • Symptoms are usually mild but include palpitations (awareness of heartbeats), a fluttering discomfort in the chest, cold skin and fatigue. Medical management usually includes drug treatment and regular doctor exams.[heart.org]
  • Nevertheless, patients who are diagnosed with the condition tend to present with the following symptoms: Fatigue Dyspnea Abdominal discomfort and ascites, due to systemic venous congestion Pulsations felt by the patient at the neck area Peripheral edema[symptoma.com]
  • Heart disease - Right atrial tumor thrombus Less common causes of TS- - Regional Tamponade - Systemic Lupus - Intracardiac wires - Prosthetic heart valve - Endocarditis Patient symptoms and Physical Examination: - signs and symptoms of MS- - Dyspena - Fatigue[quizlet.com]
  • Symptoms include a fluttering discomfort in the neck, fatigue, cold skin, and right upper quadrant abdominal discomfort.[merckmanuals.com]
Whipple Disease
  • Rare causes of tricuspid stenosis include active infective endocarditis, metabolic or enzymatic abnormalities (Fabry's, Whipple's disease), and giant blood cysts.[ncbi.nlm.nih.gov]
  • disease right atrial myxoma (generally not considered 'true' tricuspid stenosis) In these non-rheumatic causes, tricuspid stenosis can occur in isolation without any mitral valve disease 1-5.[radiopaedia.org]
  • disease Differential Diagnosis The differential diagnosis of tricuspid stenosis include valvular abnormalities causing a similar clinical presentation, and other causes of systemic venous congestion.[wikidoc.org]
Exertional Dyspnea
  • dyspnea 労作性呼吸困難 external cardiac massage (ECM)非開胸心マッサージ extraanatomical bypass非解剖学的バイパス extracorporeal circulation対外循環 extremity[四]肢、手足 f Fabry's diseaseファーブリ病 false aneurysm偽[性]動脈瘤 false lumen偽腔 familial hyperlipidemia家族性高脂[質]血[症] family history家族歴[tokyo-med.ac.jp]
Hepatomegaly
  • - Jaundice - jugular venous distention - Peripheral edema without pulmonary congestion - peripheral edema - Hepatomegaly - Jugular venous distention - ascites - cyanosis - fatigue - Sounds like mitral stenosis - Opening snap- (may occur later than MV[quizlet.com]
  • The result is chronic hepatic congestion and hepatomegaly along with peripheral edema and ascites.[pathwaymedicine.org]
  • Patients with tricuspid stenosis characteristically present with right-predominant clinical features of heart failure such as hepatomegaly, ascites, and anasarca 1-3.[radiopaedia.org]
  • Signs and Symptoms [19] Fatigue Dyspnea Abdominal discomfort (due to hepatomegaly secondary to systemic venous congestion) Pedal edema Jugular venous distension Heart murmur Physical Examination Tricuspid stenosis often co-exists with mitral stenosis,[wikidoc.org]
  • Blood flow into the pulmonary circulation is impaired and is accompanied by peripheral oedema and hepatomegaly.[patient.info]
Heart Disease
  • Bonow help you to apply all of the latest scientific knowledge and clinical strategies with Valvular Heart Disease, a companion to Braunwald’s Heart Disease.[books.google.com]
  • The congenital form accounts for approximately 0.3% of all congenital heart disease cases. The frequency of tricuspid stenosis in the older population, due to secondary causes, ranges from 0.3-3.2%.[emedicine.medscape.com]
  • […] to the developing countries due to the low prevalence of rheumatic heart disease.[wikidoc.org]
Heart Murmur
  • The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope. But many people have heart murmurs without having a problem.[icdlist.com]
  • The diagnosis of tricuspid valve stenosis usually occurs during a physical examination with the discovery of a heart murmur. Additional testing is usually performed after the discovery of a heart murmur.[rahmanicardiology.com]
  • A heart murmur had been diagnosed 28 years previously, and she had been followed at the Hospital for Sick Children, Toronto. She remained entirely symptom free during adolescence. ..[nejm.org]
  • A heart murmur produced by blood trying to flow through a stenotic valve can be heard with a stethoscope, and an x ray of the chest will show the right atrium to be enlarged.[schmidtandclark.com]
Opening Snap
  • It is best heard over the left sternal border with rumbling character and tricuspid opening snap with wide-splitting S1. It may increase in intensity with inspiration (Carvallo's sign).[en.wikipedia.org]
  • Soft opening snap Mid-diastolic rumble with presystolic accentuation On auscultation, tricuspid stenosis is often inaudible but may produce a soft opening snap and a mid-diastolic rumble with presystolic accentuation.[merckmanuals.com]
  • snap- (may occur later than MV opening snap) - Diastolic rumble heard best at apex - Both of these sounds may be accentuated with inspiration as it increases flow to the right heart. - Physician may describe a pre systolic click with atrial contraction[quizlet.com]
  • It has a rumbling character, a tricuspid opening snap with wide splitting of S1.[wikidoc.org]
  • snap僧帽弁開放音 mitral regurgitation (MR)僧帽弁逆流[症] mitral stenosis (MS) 僧帽弁狭窄[症] mitral valve 僧帽弁 mitral valve area僧帽弁口面積 mitral valve prolapse (MVP)僧帽弁逸脱[症] mitral valve replacement僧帽弁置換術 Mobitz type I blockモビッツI型ブロック Mobitz type II blockモビッツII型ブロック moist[tokyo-med.ac.jp]
Diastolic Murmur
  • A mild diastolic murmur can be heard during auscultation caused by the blood flow through the stenotic valve. It is best heard over the left sternal border with rumbling character and tricuspid opening snap with wide-splitting S1.[en.wikipedia.org]
  • Clinical examination classically reveals an elevated jugular venous pressure with a dominant a-wave and slow y-descent, and a mid-diastolic murmur that is heard on praecordial auscultation 1-3.[radiopaedia.org]
  • The differential diagnosis of tricuspid stenosis includes: Aortic regurgitation : The diastolic murmur of aortic regurgitation decreases with respiration, which is in contrast to that of tricuspid stenosis.[wikidoc.org]
  • Mitral valve stenosis is associated with a diastolic murmur because of turbulence that occurs as blood flows across the stenotic valve..[cvphysiology.com]
  • A low rumbling diastolic murmur along the left sternal border, which increases with inspiration. Tricuspid regurgitation is often also present, causing a pansystolic murmur in a similar location.[patient.info]
Jugular Venous Distention
  • venous distention - Peripheral edema without pulmonary congestion - peripheral edema - Hepatomegaly - Jugular venous distention - ascites - cyanosis - fatigue - Sounds like mitral stenosis - Opening snap- (may occur later than MV opening snap) - Diastolic[quizlet.com]
  • Jugular venous distention may occur, increasing with inspiration (Kussmaul sign). The face may become dusky and scalp veins may dilate when the patient is recumbent (suffusion sign). Hepatic congestion and peripheral edema may occur.[merckmanuals.com]
  • Isolated tricuspid stenosis is manifest by the signs and symptoms of right-sided heart failure, including hepatomegaly, hepatic dysfunction, ascites, edema, and jugular venous distention with giant A waves visible on the central venous pressure recording[tele.med.ru]

Workup

Due to symptoms caused by tricuspid valve stenosis and coexistent conditions being considerably non-specific, the complete workup for the diagnosis of tricuspid valve stenosis is extensive. It includes echocardiography, chest X-rays, computerized tomography (CT), and magnetic resonance imaging (MRI). Cardiac catheterization may also be indicated.

The imaging modality that is most effective in the diagnosis of tricuspid valve stenosis is the echocardiography. It can illustrate abnormal structural changes within the valvular orifice, such as thickening and fusion of leaflets, a diminished annulus diameter, and an increased blood velocity through the valve. It is also invaluable in detecting any other associated cardiac condition [5]. Calcification of the tricuspid valve, diastolic doming, and signs compatible with the enlargement of the right atrium are findings that agree with the diagnosis of tricuspid valve stenosis [6]. A continuous-wave Doppler ultrasound can measure transvalvular velocities which can be utilized to calculate the mean pressure gradient. In patients affected by serious tricuspid valve stenosis, the mean pressure gradient exceeds 5 mmHg [7] [8] [9].

Plain radiography of the chest can help to observe a potentially enlarged heart. The enlargement of the right atrium may be particularly pronounced. CT of the heart typically illustrates fused and abnormally thick leaflets while MRI is able to confirm the existence of diastolic doming and a restriction in the process of valvular opening. Cardiac catheterization may be used to aid in the planning of the optimal surgical procedure, as it can diagnose many aspects of cardiac pathology.

Left Anterior Fascicular Block
  • This case, as well as previous case reports, suggests that congenital tricuspid stenosis with ostium secundum atrial septal defect is associated with left anterior fascicular block.[ncbi.nlm.nih.gov]
Prominent A-Wave
  • Patients often display a prominent A Wave as atrial systole against the stenotic tricuspid valve results in an exaggerated increase in right atrial pressure and thus bulging of neck veins.[pathwaymedicine.org]
  • A prominent A wave frequently is found in the central venous pressure trace.[tele.med.ru]
Right Atrial Hypertrophy
  • Investigations ECG: findings are usually nonspecific; they may show right atrial hypertrophy (tall peaked 'p' waves), incomplete right bundle-branch block, Q waves in lead V1, and atrial fibrillation.[patient.info]
  • atrial hypertrophy. [18] Patients with TS experience frequent arrhythmias, particularly atrial flutter and/or atrial fibrillation due to the enlargement of the right atrium.[wikidoc.org]

Treatment

  • The treatment is usually by surgery (tricuspid valve replacement) or percutaneous balloon valvuloplasty.[en.wikipedia.org]
  • Aggressive treatment consisted of surgical extraction of two pacemaker leads and one pacemaker battery, replacement of the tricuspid valve and implantation of a DDD-R epicardial pacemaker.[ncbi.nlm.nih.gov]

Prognosis

Etiology

  • In over 90% of stenotic tricuspid valves, the etiology is rheumatic disease. In isolated tricuspid stenosis, the etiology is either carcinoid or congenital.[ncbi.nlm.nih.gov]
  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]

Epidemiology

  • Other cardiac anomalies are usually present. [1] Epidemiology United States data Tricuspid stenosis is rare, occurring in less than 1% of the population.[emedicine.medscape.com]
  • The epidemiology of rheumatoid arthritis in Ontario, Canada. Arthritis Rheumatol 2014;66:786–793.[jkma.org]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology Tricuspid stenosis results from alterations in the structure of the tricuspid valve that precipitate inadequate excursion of the valve leaflets.[emedicine.medscape.com]
  • This occurs in a similar manner to rheumatic mitral stenosis (see individual article for detailed discussion of this pathophysiology). 1-3 The characteristic hemodynamic feature of tricuspid stenosis is an increased diastolic pressure gradient between[radiopaedia.org]

Prevention

  • […] rheumatic fever - Prophylaxis to prevent endocarditis - rarely does the TV stenosis become so severe that these choices are required. - surgical or Balloon commissurotomy - Valve repair or replacement 2D- findings that are noted at the valve itself:[quizlet.com]
  • It functions is to prevent blood from flowing back into the right atrium. Tricuspid valve stenosis occurs when the valves leaflets are too stiff and do not open wide enough, restricting blood flow.[rahmanicardiology.com]
  • Optimal Dental Hygiene – It is essential to take proper care of the gums and teeth as a way to prevent infections. This requires routine dental visits.[rosenfeldinjurylawyers.com]
  • Prevention Rheumatic fever, the usual cause of tricuspid valve stenosis, has almost disappeared in North America and western Europe. Therefore, the number of people who acquired this condition in childhood will decline over time.[medical-dictionary.thefreedictionary.com]
  • Precautionary antibiotics are taken to prevent bacterial endocarditis (an infection of the heart tissue) when procedures such as dental surgery are necessary.[heart-valve-surgery.com]

References

Article

  1. Bhardwaja R, Sharmab R. Balloon dilatation of isolated severe tricuspid valve stenosis. Indian Heart J. 2015;67(Suppl 3): S78–S80.
  2. Rogers JH, Boiling SF. The tricuspid valve. Current perspective and evolving management of tricuspid regurgitation. Circulation. 2009;119:2718–2725
  3. Kitchin A, Turner R. Diagnosis and treatment of tricuspid stenosis. Br Heart J. 1964; 26: 354–379
  4. Bruce CJ, Connolly HM. Right-Sided Valve Disease Deserves a Little More Respect. Circulation. 2009;119:2726-2734
  5. Faletra F, La Marchesina U, Bragato R, De Chiara F. Three dimensional transthoracic echocardiography images of tricuspid stenosis. Heart. 2005;91(4):499.
  6. Pearlman AS. Role of echocardiography in the diagnosis and evaluation of severity of mitral and tricuspid stenosis. Circulation 1991;84(3 Suppl): I193-197
  7. Baumgartner H, Hung H, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EASE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22(1):1–23
  8. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15:167-184.
  9. Hatle L. Noninvasive assessment of valve lesions with Doppler ultra-
    sound. Herz 1984;9:213-221.

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Last updated: 2019-07-11 20:40