Tricuspid Stenosis

• What is tricuspid stenosis?


  Narrowing of tricuspid valve
• Pathphys of TS


  Reduction in tricuspid valve size → obstruction of blood flow from RA into RV during diastole → elevated RA pressure → RA enlargement & hypertrophy (can contribute to development of AF)

  Chronically elevated RA pressure → systemic venous congestion
• What are the signs & symptoms of TS?


  SOB

  Exercise intolerance

  Fatigue

  Cyanosis

  Abdominal swelling & discomfort

  Oedema

  Elevated JVP with prominent A-wave

  Low frequency pre-systolic (diastolic) murmur at lower left sternal border

  Hepatomegaly

  Ascites

  AF
• What are the risk factors of TS?


  Group A streptococcal (GAS) pharyngitis

  Metastatic carcinoid tumours

  Artificial tricuspid valve

  IV drug use

  Pacemaker/defibrillator leads crossing tricuspid valve orifice

  Genetic predisposition

  Age (40-59)
• What are the investigations for TS?


  Obs

  Full Hx & examination

  ECG

  • tall, peaked P waves (in II, III, V1) or RA enlargement
  • AF

  Bloods (FBC, U&Es, LFTs, CRP, Cultures)

  CXR (non-specific findings)

  Echo (TTE)

  24 hour urinary excretion of 5-hydroxy-indole acetic acid (5-HIAA) -> to assess for carcinoid heart disease
• What might a FBC show in TS?


  Polycythaemia -> may suggest chronic hypoxaemia secondary to diminished pulmonary blood flow or right-to-left shunting

  Leukocytosis -> indicates infective endocarditis
• What will an echo show in TS?


  Elevated mean tricuspid valve gradient (> 2mmHg)

  Prolonged slope of antegrade flow

  Restricted valve leaflet motion
• What are the DDx of TS?

  Cardiac tumours

  SLE

  Constrictive pericarditis

  Restrictive cardiomyopathy
• What is the treatment of congenital TR?


  Surgery + preoperative alprostadil + postoperative antiplatelet therapy
• What is the treatment of TR w/carcinoid heart disease?


  Fluid & Na restriction + loop diuretic + somatostatin analogue + valve replacement surgery or balloon dilatation
• What is the treatment of TR w/Hx of rheumatic fever?


  Mild-moderate

  • Fluid & Na restriction + loop diuretic (1st line)

  Severe

  • Surgical valve repair or replacement (1st line)
• What is the treatment of TR w/IE?


  Abx + surgery

  If cannot do surgery, just appropriate Abx