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| __NOTOC__ | | __NOTOC__ |
| {{Tricuspid stenosis}} | | {{Tricuspid stenosis}} |
| {{CMG}}; {{AE}} {{Rim}} {{FB}} | | {{CMG}} {{AE}} [[User:Mohammed Salih|Mohammed Salih, M.D.]] {{FB}} {{Rim}} <br> |
| | {{SK}} |
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| ==Overview== | | ==[[Tricuspid stenosis overview|Overview]]== |
| Tricuspid stenosis (TS) is a type of [[valvular heart disease]] where there is narrowing of the orifice of the [[tricuspid valve]] of the [[heart]]. A majority of stenotic tricuspid valves are associated with evidence of tricuspid regurgitation.<ref name="pmid19065003" /> Tricuspid stenosis is quite uncommon in developed countries due to the low incidence of [[rheumatic heart disease]], which is the commonest cause of TS.<ref name="pmid19065003" /> It is the least common valvular stenosis lesion<ref name="pmid19065003" />, and generally accompanies mitral and/or aortic valve involvement.<ref name="pmid9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226 }} </ref> Rheumatic tricuspid valve disease seldom receives much attention and can be easily overlooked on routine clinical and echocardiographic examination, which may lead to postoperative problems after successfully relieving left-sided valvular disease.<ref name="pmidPMID: 20583402">{{cite journal| author=Sultan FA, Moustafa SE, Tajik J, Warsame T, Emani U, Alharthi M et al.| title=Rheumatic tricuspid valve disease: an evidence-based systematic overview. | journal=J Heart Valve Dis | year= 2010 | volume= 19 | issue= 3 | pages= 374-82 | pmid=PMID: 20583402 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20583402 }} </ref> The clinical findings associated with rheumatic mitral valve disease are also more severe than that of rheumatic tricuspid valve disease, making it rather easy to miss the diagnosis of concomitant tricuspid stenosis (TS).<ref name="pmidPMID: 24495168" /> There is also a paucity of literature on the prevalence and management of rheumatic tricuspid valve disease<ref name="pmidPMID: 20583402" />. Most of the literature on rheumatic tricuspid stenosis are old, which may be reflective of the low incidence of rheumatic heart disease in developed countries. However, developing countries and the Indian subcontinent still have a significant prevalence of rheumatic tricuspid valve disease, occurring mostly in young women.<ref name="pmidPMID: 24495168">{{cite journal| author=Kerut KD, Kerut EK| title=Echo diagnosis of rheumatic tricuspid valve disease. | journal=Echocardiography | year= 2014 | volume= 31 | issue= 5 | pages= 680-1 | pmid=PMID: 24495168 | doi=10.1111/echo.12532 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24495168 }} </ref> It is extremely rare to have isolated acquired tricuspid stenosis.<ref name="pmidPMID: 8118123">{{cite journal| author=Saito T, Horimi H, Hasegawa T, Kamoshida T| title=Isolated tricuspid valve stenosis caused by infective endocarditis in an adult: report of a case. | journal=Surg Today | year= 1993 | volume= 23 | issue= 12 | pages= 1081-4 | pmid=PMID: 8118123 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8118123 }} </ref> Stenotic tricuspid valves are usually anatomically abnormal, and often take years to develop, with few exceptions such as congenital causes, active endocarditis.<ref name="pmid7720297" />
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| ==Classification== | | ==[[Tricuspid stenosis classification|Classification]]== |
| Tricuspid stenosis is staged based on the valve anatomy and hemodynamics, and the hemodynamic consequences.<ref name="pmid24603191" /> | |
| {| class="wikitable"
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| !Stage
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| !Definition
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| !Valve anatomy
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| !Valve hemodynamics
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| !Hemodynamic consequences
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| !Symptoms
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| |-
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| |C, D
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| |Severe TS
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| |Thickened, distorted, calcified leaflets
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| * T ½ ≥190 ms
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| * Valve area ≤1.0 cm2
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| |Right atrial / [[Inferior vena cava]] enlargement
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| * Stage C-No symptoms
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| * Stage D-Symptoms variable and dependent on the severity of associated valve disease and degree of obstruction
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| |}
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| ==Pathophysiology== | | ==[[Tricuspid stenosis pathophysiology|Pathophysiology]]== |
| TS is characterized by structural changes in the [[tricuspid valve]]. The pathophysiology of [[tricuspid valve stenosis]] depends on the underlying etiology. In rheumatic heart disease which is the most common cause of TS, there is diffuse scarring and fibrosis of the valve leaflets, fusion of the commissures, and shortening of the [[chordae tendinae|chordae tendineae]] as a result of inflammation.<ref name="pmid7720297">{{cite journal| author=Waller BF, Howard J, Fess S| title=Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part I. | journal=Clin Cardiol | year= 1995 | volume= 18 | issue= 2 | pages= 97-102 | pmid=7720297 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7720297 }} </ref> These abnormalities limit leaflet mobility and reduce the size of the tricuspid orifice, increasing the transtricuspid diastolic gradient, which can eventually result in systemic venous hypertension and congestion.<ref name="pmid24603191" />
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| The pathophysiology of tricuspid stenosis based on the underlying etiology:<ref name="pmid7720297" />
| | ==[[Tricuspid stenosis causes|Causes]]== |
| * '''Rheumatic tricuspid stenosis''':
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| ** Diffuse scarring and fibrosis of the valve leaflets from inflammation. Fusion of the commissures may or may not occur.
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| ** [[Chordae tendineae]] may become thickened and shortened.
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| ** As a result of the dense collagen and elastic fibers that make up leaflet tissue, the normal leaflet layers become significantly distorted.
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| * [[Carcinoid|Carcinoid heart disease]]:
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| ** Fibrous white plaques located on the valvular and mural [[endocardium]] are characteristic presentations of carcinoid valve lesions.
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| ** Valve leaflets become thick, rigid and smaller in area.
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| ** Atrial and ventricular surfaces of the valve structure contain fibrous tissue proliferation.
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| * '''Congenital tricuspid stenosis''':
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| ** More common in infants
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| ** Lesions may present in a number of different ways, either singularly or in any combination of the following:
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| *** Incompletely developed leaflets
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| *** Shortened or malformed chordae
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| *** Small annuli
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| *** [[Papillary muscle|Papillary muscles]] of abnormal size and number
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| * Infective endocarditis:
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| ** Stenosis may develop as a result of large infected vegetations obstructing the opening of the [[tricuspid valve]].
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| * '''Mechanical obstruction''' of flow through the [[tricuspid valve]]:
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| ** Supravalvular obstruction from congenital diaphragms
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| ** Intracardiac or extracardiac tumors
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| ** [[Thrombosis]] or [[emboli]]
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| ** Large [[endocarditis]] vegetations
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| ==Causes== | | ==[[Tricuspid stenosis differential diagnosis|Differentiating Tricuspid stenosis from other Diseases]]== |
| The most common cause of TS is [[rheumatic heart disease]]. Other causes of [[TS]] include [[carcinoid syndrome]], [[congenital]] abnormalities, endocarditis, [[lupus]], and mechanical obstruction by a [[tumor]].<ref name="pmid7720297" /><ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref>
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| | ==[[Tricuspid stenosis epidemiology and demographics|Epidemiology and Demographics]]== |
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| ===Common Causes<ref name="pmid7720297" />=== | | ==[[Tricuspid stenosis risk factors|Risk Factors]]== |
| * [[Rheumatic heart disease]] (majority of the cases)
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| * [[Carcinoid syndrome]]
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| * [[Congenital]]
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| Etiology of Tricuspid stenosis in operatively excised valves in patients >15years<ref name="pmid7720297" />
| | ==[[Tricuspid stenosis screening|Screening]]== |
| {| class="wikitable"
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| ! colspan="5" |Etiology of tricuspid stenosis in 97 operatively excised stenotic tricuspid valves
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| |-
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| ! rowspan="2" |Rheumatic
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| ! rowspan="2" |Carcinoid
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| ! colspan="3" |Congenital
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| |-
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| !Ebstein's anomaly
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| !Complex heart disease
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| !Shortened chordae and/or fused commissure
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| |-
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| |90
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| |3
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| |1
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| |2
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| |1
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| |}
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| | |
| ===Causes by Organ System===
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| {|style="width:80%; height:100px" border="1"
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| | style="width:25%" bgcolor="lightsteelblue" ; border="1" |'''Cardiovascular'''
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| | style="width:75%" bgcolor="beige" ; border="1" | [[Congenital heart disease]], [[cardiac tumor]], saphenous vein bypass graft aneurysm,<ref name="pmidPMID: 27217436">{{cite journal| author=Jellis CL, Navia JL, Flamm SD, Rodriguez LL| title=Severe Functional Tricuspid Stenosis Secondary to a Giant Saphenous Vein Bypass Graft Aneurysm. | journal=Circulation | year= 2016 | volume= 133 | issue= 21 | pages= 2099-102 | pmid=PMID: 27217436 | doi=10.1161/CIRCULATIONAHA.115.014772 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27217436 }} </ref> [[Ebstein's anomaly]], [[endomyocardial fibrosis]], [[infective endocarditis]], [[myxoma]], [[rheumatic heart disease]]
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| |-
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| | bgcolor="lightsteelblue" | '''Chemical/Poisoning'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Dental'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Dermatologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Drug Side Effect'''
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| | bgcolor="beige" | [[Methysergide]]
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Ear Nose Throat'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Endocrine'''
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| | bgcolor="beige" | [[Carcinoid syndrome]]
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| |- bgcolor="lightsteelblue"
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| | '''Environmental'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Gastroenterologic'''
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| | bgcolor="beige" | No underlying causes
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| |- bgcolor="lightsteelblue"
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| | '''Genetic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Hematologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Iatrogenic'''
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| | bgcolor="beige" | [[Pacemaker|Pacemaker infection]], [[pacemaker|pacemaker leads]]<ref name="pmid16800373">{{cite journal| author=Taira K, Suzuki A, Fujino A, Watanabe T, Ogyu A, Ashikawa K| title=Tricuspid valve stenosis related to subvalvular adhesion of pacemaker lead: a case report. | journal=J Cardiol | year= 2006 | volume= 47 | issue= 6 | pages= 301-6 | pmid=16800373 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16800373 }} </ref>, device closure of right coronary arteriovenous fistula.<ref name="pmidPMID: 26603866">{{cite journal| author=Changchien C, Lin MT, Wang CC, Liu HM, Wang CC, Chiu SN et al.| title=Neonatal tricuspid stenosis caused by device closure of a large coronary fistula. | journal=EuroIntervention | year= 2015 | volume= 11 | issue= 7 | pages= e1 | pmid=PMID: 26603866 | doi=10.4244/EIJV11I7A162 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26603866 }} </ref>
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Infectious Disease'''
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| | bgcolor="beige" | [[Infective endocarditis]]
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Musculoskeletal/Orthopedic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Neurologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Nutritional/Metabolic'''
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| | bgcolor="beige" | [[Fabry disease]], [[Whipple's disease]]
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Obstetric/Gynecologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Oncologic'''
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| | bgcolor="beige" | [[Carcinoid syndrome]], [[cardiac tumor]], [[intravenous leiomyomatous tumor]],<ref name="pmid15226964">{{cite journal| author=Nili M, Liban E, Levy MJ| title=Tricuspid stenosis due to intravenous leiomyomatosis--a call for caution: case report and review of the literature. | journal=Tex Heart Inst J | year= 1982 | volume= 9 | issue= 2 | pages= 231-5 | pmid=15226964 | doi= | pmc=PMC351617 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15226964 }} </ref> [[metastatic tumor]], [[myxoma]]
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Ophthalmologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Overdose/Toxicity'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Psychiatric'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Pulmonary'''
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| | bgcolor="beige" | No underlying causes
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| |- bgcolor="lightsteelblue"
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| | '''Renal/Electrolyte'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Rheumatology/Immunology/Allergy'''
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| | bgcolor="beige" | [[Amyloidosis]],<ref name="pmid24797117">{{cite journal| author=Kim KH, Park CH, Park HS, Kim YR, Choi EY| title=Amyloidosis-induced tricuspid stenosis mimicking rheumatic heart disease. | journal=Eur Heart J Cardiovasc Imaging | year= 2014 | volume= 15 | issue= 10 | pages= 1167 | pmid=24797117 | doi=10.1093/ehjci/jeu075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24797117 }} </ref> [[systemic lupus erythematosus]]
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| |- bgcolor="lightsteelblue"
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| | '''Sexual'''
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| | bgcolor="beige" | No underlying causes
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| |-
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| |- bgcolor="lightsteelblue"
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| | '''Trauma'''
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| | bgcolor="beige" | No underlying causes
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| |- bgcolor="lightsteelblue"
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| | '''Urologic'''
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| | bgcolor="beige" | No underlying causes
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| |-
| |
| |- bgcolor="lightsteelblue"
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| | '''Miscellaneous'''
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| | bgcolor="beige" | [[Cyst|Giant blood cyst]]
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| |-
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| |}
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| ===Causes by Alphabetical Order===
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| * [[Amyloidosis]]<ref name="pmid24797117">{{cite journal| author=Kim KH, Park CH, Park HS, Kim YR, Choi EY| title=Amyloidosis-induced tricuspid stenosis mimicking rheumatic heart disease. | journal=Eur Heart J Cardiovasc Imaging | year= 2014 | volume= 15 | issue= 10 | pages= 1167 | pmid=24797117 | doi=10.1093/ehjci/jeu075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24797117 }} </ref>
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| * [[Carcinoid syndrome]]
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| * [[Cardiac tumor]]
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| * [[Congenital heart disease]]
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| * [[Ebstein's anomaly]]
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| * [[Endomyocardial fibrosis]]
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| * [[Fabry disease]]
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| * [[Cyst|Giant blood cyst]]
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| * [[Infective endocarditis]]
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| *[[Intravenous leiomyomatous tumor]]<ref name="pmid15226964">{{cite journal| author=Nili M, Liban E, Levy MJ| title=Tricuspid stenosis due to intravenous leiomyomatosis--a call for caution: case report and review of the literature. | journal=Tex Heart Inst J | year= 1982 | volume= 9 | issue= 2 | pages= 231-5 | pmid=15226964 | doi= | pmc=PMC351617 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15226964 }} </ref>
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| * [[Metastatic tumor]]
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| * [[Myxoma]]
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| * [[Pacemaker|Pacemaker infection]]
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| * [[Pacemaker|Pacemaker leads]]
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| * [[Rheumatic heart disease]]
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| * [[Systemic lupus erythematosus]]
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| * [[Whipple's disease]]
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| ==Differential Diagnosis==
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| The differential diagnosis of [[tricuspid stenosis]] include valvular abnormalities causing a similar clinical presentation, and other causes of systemic venous congestion. The [[heart murmur]] of tricuspid stenosis must be differentiated from that of other valvular diseases. However, it should be noted that tricuspid stenosis often co-exist with other valvular pathologies such as [[tricuspid regurgitation]], [[mitral valve]] and aortic valve abnormalities.<ref name="pmid7720297">{{cite journal| author=Waller BF, Howard J, Fess S| title=Pathology of tricuspid valve stenosis and pure tricuspid regurgitation--Part I. | journal=Clin Cardiol | year= 1995 | volume= 18 | issue= 2 | pages= 97-102 | pmid=7720297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7720297 }} </ref> Tricuspid stenosis is characterized by a mid diastolic murmur best heard over the left sternal border. It has a rumbling character, a tricuspid opening snap with wide splitting of S1. The differential diagnosis of tricuspid stenosis includes:
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| * [[Aortic regurgitation]]: The diastolic murmur of [[aortic regurgitation]] decreases with respiration, which is in contrast to that of [[tricuspid stenosis]].
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| * [[Mitral regurgitation]]: The murmur of [[mitral regurgitation]] is blowing, soft and best heard at the apex.
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| * [[Mitral stenosis]]: The murmur of [[mitral stenosis]] is mid-diastolic, rumbling, and best heard after the opening snap.
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| * [[Tricuspid regurgitation]]: The murmur of [[tricuspid regurgitation]] is blowing, holosystolic, and best heard over the fourth intercostal area at the left sternal border.
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| Tricuspid stenosis should also be differentiated from diseases causing a similar clinical presentation,such as: | |
| * [[Tricuspid atresia (patient information)|Tricuspid atresia]]
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| * [[Pericarditis (patient information)|Constrictive pericarditis]]
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| * [[Restrictive cardiomyopathy]]
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| * [[Atrial myxoma]]
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| ==Epidemiology and Demographics==
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| TS is the least common valvular disease. TS is rarely an isolated disease, it is mostly associated with mitral and/or aortic valve abnormalities with/without concomitant [[tricuspid regurgitation]].
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| ==== Prevalence ====
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| A prospective study of the echocardiographic profile of tricuspid valve disease in 788 patients with rheumatic heart disease in India was done. 9% of the patients had tricuspid valve disease and half of these patients with tricuspid valve disease had tricuspid stenosis with/without tricuspid regurgitation.<ref name="pmid10636636">{{cite journal| author=Goswami KC, Rao MB, Dev V, Shrivastava S| title=Juvenile TS and rheumatic tricuspid valve disease: an echocardiographic study. | journal=Int J Cardiol | year= 1999 | volume= 72 | issue= 1 | pages= 83-6 | pmid=10636636 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10636636 }} </ref> The prevalence of TS is lower in developed countries compared to the developing countries due to the low prevalence of [[rheumatic heart disease]].
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| ==== Gender ====
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| Most patients with rheumatic tricuspid stenosis are young women with mitral and aortic valve disease.<ref name="pmid9665226" />
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| ==Risk Factors==
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| One of the most recognized risk factors for TS is [[rheumatic fever]].<ref name="pmidPMID: 18692660">{{cite journal| author=Bernal JM, Pontón A, Diaz B, Llorca J, García I, Sarralde A et al.| title=Surgery for rheumatic tricuspid valve disease: a 30-year experience. | journal=J Thorac Cardiovasc Surg | year= 2008 | volume= 136 | issue= 2 | pages= 476-81 | pmid=PMID: 18692660 | doi=10.1016/j.jtcvs.2008.02.065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18692660 }} </ref>
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| ==Natural History, Complications, and Prognosis==
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| ==== Natural history ====
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| The natural course of tricuspid stenosis is not well defined. It is extremely rare for TS to occur in isolation, it is usually associated with existing mitral valve disease with/without concormitant tricuspid regurgitation.<ref name="pmid9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226 }} </ref> The most common cause of TS is rheumatic heart disease and it is usually associated with coexisting mitral valve and/or aortic valve abnormality.<ref name="pmid9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226 }} </ref> TS of rheumatic etiology usually occurs with tricuspid regurgitation. Tricuspid stenosis often takes years to develop,<ref name="pmid7720297" /> with some exceptions such as congenital causes. Complications of tricuspid stenosis include [[heart failure]], [[liver failure]], and [[stroke]].<ref name="pmid15786615">{{cite journal| author=Diaof M, Ba SA, Kane A, Sarr M, Diop IB, Diouf SM| title=[Tricuspid valve stenosis. A prospective study of 35 cases]. | journal=Dakar Med | year= 2004 | volume= 49 | issue= 2 | pages= 96-100 | pmid=15786615 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15786615 }} </ref>
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| ==== Complications of TS<ref name="pmid9665226" /><ref name="pmid15786615" /> ====
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| * [[Right atrial enlargement]]
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| * [[Atrial fibrillation]]
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| * [[Heart failure]]
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| * [[Infective endocarditis]]
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| * [[Cerebrovascular accident]]
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| * [[Liver failure]]
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| ==== Prognosis ====
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| With medical intervention, severe [[tricuspid stenosis]] appears well tolerated over several years of follow-up.<ref name="pmid9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226 }} </ref>
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| | ==[[Tricuspid stenosis natural history, complications, and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
| ===History and Symptoms===
| | [[Tricuspid stenosis diagnostic study of choice|Diagnostic study of choice]] | [[Tricuspid stenosis history and symptoms|History and Symptoms]] | [[Tricuspid stenosis physical examination|Physical Examination]] | [[Tricuspid stenosis laboratory findings|Laboratory Findings]] | [[Tricuspid stenosis electrocardiogram|Electrocardiogram]] | [[Tricuspid stenosis x ray|X-Ray Findings]] | [[Tricuspid stenosis echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Tricuspid stenosis CT scan|CT-Scan Findings]] | [[Tricuspid stenosis MRI|MRI Findings]] | [[Tricuspid stenosis other imaging findings|Other Imaging Findings]] | [[Tricuspid stenosis other diagnostic studies|Other Diagnostic Studies]] |
| Tricuspid stenosis is mostly associated with [[mitral valve]] abnormalities.<ref name="pmidPMID: 9665226">{{cite journal| author=Roguin A, Rinkevich D, Milo S, Markiewicz W, Reisner SA| title=Long-term follow-up of patients with severe rheumatic tricuspid stenosis. | journal=Am Heart J | year= 1998 | volume= 136 | issue= 1 | pages= 103-8 | pmid=PMID: 9665226 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9665226 }} </ref> Common symptoms include [[dyspnea]], [[peripheral edema]], and [[fatigue]]. | |
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| ===Signs and Symptoms<ref name="pmidPMID: 9665226" />===
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| * [[Fatigue]]
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| *[[Dyspnea]]
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| * [[Abdominal discomfort]] (due to [[hepatomegaly]] secondary to systemic venous congestion)
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| * [[Pedal edema]]
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| * [[Jugular venous distension]]
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| * [[Heart murmur]]
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| ===Physical Examination===
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| Tricuspid stenosis often co-exists with [[mitral stenosis]], thus depending on the severity of mitral valve pathology, symptoms differ. The diagnosis of TS may also be missed when they coexist. Patients can lay flat without any symptoms in the absence of serious mitral valve pathology and thus, not present with any signs of [[dyspnea]]. Characteristic findings of TS include an opening snap and a low to medium pitch diastolic rumbling murmur that is localized to the lower left sternal border (fourth intercostal space) with inspiratory accentuation.<ref name="pmidPMID: 18222317">{{cite journal| author=Shah PM, Raney AA| title=Tricuspid valve disease. | journal=Curr Probl Cardiol | year= 2008 | volume= 33 | issue= 2 | pages= 47-84 | pmid=PMID: 18222317 | doi=10.1016/j.cpcardiol.2007.10.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18222317 }} </ref> | |
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| ===Echocardiogram===
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| [[Transthoracic echocardiography]] ([[TTE]]) should be performed among patients with suspected TS to confirm the diagnosis, determine the etiology, and establish the baseline severity. TTE commonly reveals findings associated with other valvular diseases, such as [[tricuspid regurgitation]] and/or [[mitral stenosis]]. TS is mainly characterized by an elevated transvalvular gradient.<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref> [[TTE]] helps in the determination of the anatomic and hemodynamic characteristics of the [[tricuspid valve]]. TTE allows the evaluation of the following:<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref>
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| * [[Tricuspid valve]] thickening and calcification
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| * Chordal thickening and calcification
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| * Decreased mobility
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| * Immobility of the leaflets (suggestive of [[carcinoid syndrome]])
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| * [[Tumor]]s or [[metastatic lesions]]
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| * Valvular vegetations (suggestive of [[infective endocarditis]])
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| * Right atrial ball valve [[thrombus]]
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| [[Doppler echocardiography]] is useful to assess the severity of TS through the evaluation of the transvalvular gradient. TS is mainly characterized by an elevated transvalvular gradient.<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref>. The assessment of the [[tricuspid valve]] area is limited by the common association of TS with [[tricuspid regurgitation]]. The coexistence of tricuspid regurgitation causes the underestimation of the tricuspid valvular area. A tricuspid valve area < 1.0 cm<sup>2</sup> is associated with increased severity of the TS.<ref name="pmid19065003" />
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| === Findings Associated with Increased Severity===
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| TTE findings that are associated with increased severity of tricuspid stenosis include:<ref name="pmid19065003">{{cite journal| author=Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al.| title=Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. | journal=Eur J Echocardiogr | year= 2009 | volume= 10 | issue= 1 | pages= 1-25 | pmid=19065003 | doi=10.1093/ejechocard/jen303 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19065003 }} </ref>
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| * Mean pressure gradient >5 mm Hg,
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| * Pressure half-time >190 milliseconds
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| * Tricuspid valve area < 1.0 cm2
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| * Enlargement of the [[right atrium]]
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| * Enlargement of the [[inferior vena cava]]
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| ==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>==
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.''' [[TTE]] is indicated in patients with [[TS]] to assess the anatomy of the valve complex, evaluate severity of stenosis, and characterize any associated regurgitation and/or left-sided valve disease. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| ===Electrocardiogram===
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| The [[electrocardiogram]] of patients with TS can demonstrate a sinus rhythm with or without right atrial hypertrophy.<ref name="pmid15786615">{{cite journal| author=Diaof M, Ba SA, Kane A, Sarr M, Diop IB, Diouf SM| title=[Tricuspid valve stenosis. A prospective study of 35 cases]. | journal=Dakar Med | year= 2004 | volume= 49 | issue= 2 | pages= 96-100 | pmid=15786615 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15786615 }} </ref> Patients with TS experience frequent arrhythmias, particularly [[atrial flutter]] and/or [[atrial fibrillation]] due to the enlargement of the [[right atrium]]. EKG findings suggestive of coexisting mitral valve disease can also be seen.
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| ===Chest X ray===
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| The chest X-ray in a patient with [[tricuspid stenosis]] may show right atrial enlargement. The heart size can range from a normal-sized heart to [[cardiomegaly]], with additional findings suggestive of coexisting valvular pathology such as [[mitral stenosis]].
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| ===Cardiac MRI===
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| While echocardiography remains the diagnostic imaging modality of choice, [[cardiac MRI]] is useful to evaluate tricuspid stenosis when the results of the [[echocardiography]] are insufficient.
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| ==ACC/AHA Guidelines- ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance<ref name="pmid20479157">{{cite journal| author=American College of Cardiology Foundation Task Force on Expert Consensus Documents. Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA et al.| title=ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. | journal=Circulation | year= 2010 | volume= 121 | issue= 22 | pages= 2462-508 | pmid=20479157 | doi=10.1161/CIR.0b013e3181d44a8f | pmc=PMC3034132 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20479157 }} </ref> (DO NOT EDIT)==
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| {{cquote|
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| CMR may be used for assessing individuals with valvular heart disease in which evaluation of valvular stenosis, regurgitation, para- or perivalvular masses, perivalvular complications of infectious processes, or prosthetic valve disease are needed. CMR may be useful in identifying serial changes in LV volumes or mass in patients with valvular dysfunction.
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| }}
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| ===Cardiac Catheterization===
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| While [[echocardiography]] remains the diagnostic imaging modality of choice, [[cardiac catheterization]] is useful to evaluate tricuspid stenosis when the results of the non-invasive testing are insufficient, particularly among patients who are being evaluated for other conditions such as [[mitral stenosis]] and [[pulmonary hypertension]].<ref name="pmid24603191">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=J Am Coll Cardiol | year= 2014 | volume= 63 | issue= 22 | pages= e57-185 | pmid=24603191 | doi=10.1016/j.jacc.2014.02.536 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24603191 }} </ref> In the older pre-surgery population, [[cardiac catheterization]] may be necessary in order to assess concomitant artery disease.
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| Catheterization of the right heart is useful for the evaluation of:
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| * The gradient across the [[tricuspid valve]]
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| * Associated congenital defects
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| Catheterization of the left heart is useful for the assessment of hemodynamic changes related to the [[aortic valve|aortic]] and [[mitral valve]]s in patients with [[rheumatic heart disease]].
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| ==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>==
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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| | bgcolor="lemonchiffon" |<nowiki>"</nowiki>'''1.''' Invasive hemodynamic assessment of severity of [[TS]] may be considered in symptomatic patients when clinical and noninvasive data are discordant. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| ==Treatment== | | ==Treatment== |
| ===Medical Therapy===
| | [[Tricuspid stenosis medical therapy|Medical Therapy]] | [[Tricuspid stenosis interventions|Interventions]] | [[Tricuspid stenosis surgery|Surgery]] | [[Tricuspid stenosis primary prevention|Primary Prevention]] | [[Tricuspid stenosis secondary prevention|Secondary Prevention]] | [[Tricuspid stenosis cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Tricuspid stenosis future or investigational therapies|Future or Investigational Therapies]] |
| Medical therapy with [[diuretics]] and sodium restriction is the mainstay of treatment among patients with TS complicated by systemic and pulmonary congestion. Patients with TS should receive medical therapy for [[left heart failure]], and/or [[pulmonary hypertension]] if they are present.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>
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| ===Surgery===
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| [[Tricuspid valve]] surgery is recommended for patients undergoing surgical intervention for left valvular disease as well as among patients with severe symptomatic isolated TS.<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref> | |
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| ==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= | issue= | pages= | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref>==
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| {|class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |- | |
| | bgcolor="lightgreen" |<nowiki>"</nowiki>'''1.'''Tricuspid valve surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
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| | ==Case Studies== |
| | [[Category: (name of the system)]] |
| | [[Tricuspid stenosis case study one|Case #1]] |
| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |