Tricuspid Stenosis

Tricuspid stenosis is uncommon in adult patients; in nearly all cases, it is due to rheumatic disease in association with rheumatic mitral involvement. (Otto, Clinical Echocardiography 6e)

Tricuspid stenosis is rare. Causes include rheumatic heart disease (the most common cause), carcinoid heart disease, and congenital abnormalities. Mass lesions in the right atrium (myxomas, thrombi, and vegetations) may cause RV inflow obstruction, leading to functional tricuspid stenosis. (Practical Perioperative TOE)

TS is usually rheumatic and associated with mitral valve involvement. Another cause of TS is carcinoid valve disease, which coexists with TR and pulmonary valve involvement. Infrequently, congenital anomalies, lead-induced adhesions, or masses obstructing RV inflow (tumour, thrombus, or vegetation) can lead to TS. (EACVI Textbook of Echocardiography)

Native tricuspid stenosis (TS) is unusual, most commonly occurring due to rheumatic valve disease in association with MS. Other causes include pacemaker-associated stenosis, carcinoid, and obstruction by tumour. (Oxford Critical Care Echo)

Tricuspid stenosis (TS) is an uncommon finding in adults and is always associated with various degrees of TR, leading to a further increase in transvalvular gradient and right atrial pressures. (EACVI Textbook of Echocardiography)

Dilation of RA and inferior vena cava supports the diagnosis of significant TS. (EACVI Textbook of Echocardiography)

Features indicating haemodynamically important TS include: mean pressure gradient >5 mmHg; inflow VTI >60 cm; PHT >190 msec; valve area (continuity equation) <1 cm2; >moderate right atrial enlargement and a dilated inferior vena cava. (Oxford Critical Care Echo)

Tricuspid stenosis is rare and almost always rheumatic, accompanying mitral (and often aortic) disease, with carcinoid the other classic cause. Work through it in order: define valve morphology and mechanism, build severity from the diastolic gradient and valve area — averaged carefully over the respiratory cycle and several beats — assess the dilated right atrium and systemic venous congestion, then integrate with the coexisting left-sided valve disease that almost always accompanies it.

2D echo images show thickening and shortening of the tricuspid valve leaflets (Fig. 11.30). Commissural fusion and diastolic bowing indicate rheumatic disease. (Otto, Clinical Echocardiography 6e)

Typical rheumatic changes are represented by leaflet thickening, restricted opening with diastolic doming (Fig. 37.5c) and commissural fusion, which is best appreciated on en face 3DE views of the TV (Fig. 37.5d). (EACVI Textbook of Echocardiography)

The examination usually starts with a qualitative assessment of TV mobility from multiple 2DE views and/or on en face TV rendering by 3DE. This step is particularly important in order to identify the limited leaflet separation, which can pass unnoticed in the presence of significant TR. (EACVI Textbook of Echocardiography)

Rheumatic disease causes leaflet thickening (usually starting at the leaflet tips) and diastolic doming. There may be accompanying thickening of the subvalvular structures and calcification of the leaflets. In the transgastric basal short-axis view (with the image centered on the TV), commissural fusion may be evident. (Practical Perioperative TOE)

The tricuspid valve should be inspected using multiple 2D echo windows for leaflet thickening and/or calcification, restriction, and doming. (Oxford Critical Care Echo)

Carcinoid heart disease affects both tricuspid and pulmonic valves and can lead either to stenosis or to regurgitation. (Otto, Clinical Echocardiography 6e)

Carcinoid heart disease (seen with metastatic carcinoid tumor to the liver) is characterized by thickened, shortened, and immobile tricuspid valve leaflets with resultant tricuspid regurgitation or, less often, tricuspid valve stenosis. (Otto, Clinical Echocardiography 6e)

In carcinoid disease, the pathognomonic stiffness and immobility of the leaflets give the TV a 'frozen' appearance (Fig. 37.5e,f). (EACVI Textbook of Echocardiography)

Carcinoid heart disease causes characteristic thickening, shortening, and immobility of the tricuspid leaflets and may result in stenosis. A search should also be made for a thrombus in the right atrium. (Practical Perioperative TOE)

Rheumatic tricuspid stenosis may be difficult to appreciate on 2D imaging. Doppler flow patterns are similar to those seen in mitral stenosis, and the same quantitative methods for the evaluation of stenosis severity can be applied. (Otto, Clinical Echocardiography 6e)

Doppler recordings of the transvalvular flow velocity allow for the calculation of mean gradient and pressure half-time valve area, as described for the mitral valve. (Otto, Clinical Echocardiography 6e)

Mean pressure gradient may be calculated by from the velocity time integral (VTI) of the diastolic CW Doppler envelope recorded from the apical four-chamber view or low parasternal view. (EACVI Textbook of Echocardiography)

TS is characterized by an increase in transvalvular velocity recorded by CW Doppler. (Oxford Critical Care Echo)

Although it lacks robust validation, a pressure half-time (PHT) of 190 ms or higher is supportive for a significant TS. (EACVI Textbook of Echocardiography)

A VTI greater than 60 cm and a mean pressure gradient of at least 5 mmHg at a heart rate of 70-80 beats/min generally indicate a haemodynamically significant TS. (EACVI Textbook of Echocardiography)

The TV functional area can be calculated by the continuity equation, but it can be difficult due to the limitations of 2DE for TV annulus sizing and in stroke volume calculation by Doppler methods in case of significant TR or AR; TV area of 1 cm2 or less by the continuity equation is considered significant. (EACVI Textbook of Echocardiography)

Features indicating haemodynamically important TS include: mean pressure gradient >5 mmHg; inflow VTI >60 cm; PHT >190 msec; valve area (continuity equation) <1 cm2; >moderate right atrial enlargement and a dilated inferior vena cava. (Oxford Critical Care Echo)

Normal values are less than those for the MV: the normal peak E wave velocity is 0.5 m/sec (range = 0.3 to 0.7 m/sec) and a mean pressure gradient of more than 5 mm Hg is consistent with severe stenosis. (Practical Perioperative TOE)

Mean pressure gradient ... represents the most versatile marker of critical valve stenosis with cut-offs greater than 40 mmHg for aortic stenosis, greater than 10 mmHg for mitral stenosis, and 5 mmHg or higher for tricuspid stenosis. (EACVI Textbook of Echocardiography)

Transvalvular gradients are influenced not only by TS, but also by coexisting TR, RV/RA compliance, and heart rate. (EACVI Textbook of Echocardiography)

Respiration will normally affect transtricuspid diastolic velocities and therefore all measurements should be either averaged throughout the respiratory cycle or taken at end-expiration (spontaneously breathing patients). (Oxford Critical Care Echo)

This step is particularly important in order to identify the limited leaflet separation, which can pass unnoticed in the presence of significant TR. (EACVI Textbook of Echocardiography)

Peak transtricuspid velocity is also elevated in the presence of increased cardiac output and tricuspid regurgitation. (Practical Perioperative TOE)

TS is frequently associated with regurgitation, which confounds Doppler evaluation of its severity, and only rarely haemodynamically important in a critically ill patient. (Oxford Critical Care Echo)

Dilation of RA and inferior vena cava supports the diagnosis of significant TS. (EACVI Textbook of Echocardiography)

Features indicating haemodynamically important TS include: ... >moderate right atrial enlargement and a dilated inferior vena cava. (Oxford Critical Care Echo)

In the apical four-chamber view (A), thickened valve leaflets (arrow) and RA enlargement are seen. (Otto, Clinical Echocardiography 6e)

Tricuspid stenosis (TS) ... is always associated with various degrees of TR, leading to a further increase in transvalvular gradient and right atrial pressures. (EACVI Textbook of Echocardiography)

Tricuspid stenosis is uncommon in adult patients; in nearly all cases, it is due to rheumatic disease in association with rheumatic mitral involvement. (Otto, Clinical Echocardiography 6e)

TS is usually rheumatic and associated with mitral valve involvement. Another cause of TS is carcinoid valve disease, which coexists with TR and pulmonary valve involvement. (EACVI Textbook of Echocardiography)

Native tricuspid stenosis (TS) is unusual, most commonly occurring due to rheumatic valve disease in association with MS. (Oxford Critical Care Echo)

Rheumatic disease involves the tricuspid valve in approximately 20% to 30% of cases, nearly always occurring in conjunction with mitral and aortic valve involvement. (Otto, Clinical Echocardiography 6e)

When assessing the severity of TS, usually more than one parameter is needed for an accurate diagnosis. (EACVI Textbook of Echocardiography)

As with all valvular disease, echocardiographic findings must be interpreted within the clinical context. (Oxford Critical Care Echo)

In the perioperative setting, the issue that arises most frequently is whether a tricuspid annuloplasty ring is required for functional tricuspid regurgitation in a patient undergoing surgery for left-sided heart disease (usually mitral regurgitation or stenosis). (Practical Perioperative TOE)

Careful evaluation of tricuspid regurgitation severity is especially important preoperatively in case tricuspid annuloplasty is needed at the time of mitral valve surgery. (Otto, Clinical Echocardiography 6e)

Triage status: Orphan verbatim excerpts gathered for tricuspid stenosis that did not fit cleanly into a specific Q&A above. Re-home into the appropriate page section (mimics/differential, colour Doppler, carcinoid pulmonary involvement) on review.

Right atrial (RA) tumors, large vegetations, or a large atrial thrombus (which may have embolized from the venous bed) can obstruct right ventricular (RV) inflow and mimic tricuspid stenosis. (Otto, Clinical Echocardiography 6e)

Colour Doppler imaging may indicate a mosaic colour pattern due to jet turbulence, with a convergence zone on the atrial side of TV leaflets. (EACVI Textbook of Echocardiography)

The TV anatomical area is still valid in case of significant TR and can be measured by 3DE (Fig. 37.5d,f). (EACVI Textbook of Echocardiography)

TTE is better for assessing the etiology and severity of tricuspid stenosis, but in the intraoperative setting, examination with TEE is useful to rule out significant stenosis following TV repair. (Practical Perioperative TOE)

Patients with tricuspid stenosis and/or more than mild tricuspid regurgitation in whom assessment of tricuspid valve morphology and severity of regurgitation will be clinically relevant (right heart failure, candidates to left heart cardiac surgery, etc.). (EACVI Textbook of Echocardiography)

Note: BSE tricuspid & pulmonary valve guideline 2020 (PMC8052586) and EAE/ASE valve stenosis recommendations were not retrievable in this session (PMC blocked by reCAPTCHA); excerpts above are all from the mounted textbooks.