Diagnosis Of Tricuspid Stenosis Research Articles

Right-Sided Valve Disease Deserves a Little More Respect

Historically, right-sided valvular disease has received less attention from clinicians and researchers than left-sided valve disease, in part because of a protracted latent asymptomatic period. Moreover, because tricuspid regurgitation (TR) is often due to left-sided valve disease and pulmonary regurgitation (PR) is often secondary to congenital cardiac disease, the underlying disorder rather than the valve lesion tends to dominate the clinical picture. It is increasingly recognized that right-sided valve disease is not benign and has a significant and independent impact on morbidity and mortality. Today, diagnostic techniques and appropriate management strategies for patients with right-sided valve disease are established and continually refined. In this era of increasing awareness and improved treatment options for patients with valve disease, it is important that clinicians consider the diagnosis of right-sided valve disease, understand its pathophysiology, choose appropriate confirmatory testing, and refer patients for timely intervention to prevent clinical deterioration with associated adverse consequences. This review examines the causes of right-sided valve disease and the latest diagnostic advances and treatment options for these often-neglected valve lesions. Patients with native right-sided valve disease are rarely affected by endocarditis, and indications for prophylaxis have recently changed.1 ### Tricuspid Regurgitation TR that is at least moderate in severity is most frequently “functional” in nature and by definition not related to primary tricuspid valve (TV) leaflet pathology but rather secondary to another disease process causing right ventricular (RV) dilatation, distortion of the subvalvular apparatus, tricuspid annular dilatation, or a combination of these. Furthermore, a moderate or greater degree of TR, regardless of primary origin, usually engenders additional TR as a result of the adverse hemodynamic consequence of RV volume overload. Causes of clinically significant TR are outlined in Table 1; 2 classic examples of primary tricuspid leaflet pathology are demonstrated in Figure 1. View this table: Table 1. Causes of TV …

Diagnosis of tricuspid stenosis by M-mode and two-dimensional echocardiography

A decreased diastolic slope (EF slope) of the tricuspid valve on the M-mode echocardiogram may not indicate the presence of tricuspid stenosis (TS). To explore diagnostic echocardiographic signs of TS, we examined an M-mode and 2-dimensional (2-D) echocardiogram in 9 patients with documented TS of rheumatic origin and in 14 patients with rheumatic heart disease who showed a decreased EF slope (< 40 mm/s) but did not have TS. By M-mode echocardiography, the EF slope was not different between patients with TS (24.4 ± 2.2 mm/s) and those without TS (27.4 ± 2.0 mm/s). The early diastolic excursion (DE amplitude) of the tricuspid valve was significantly lower (p < 0.001) in patients with TS (7.6 ± 1.0 mm) than in patients without TS (13.9 ± 0.6 mm). Two-dimensional echocardiograms of the tricuspid valve revealed diastolic doming in all patients with TS. Diastolic doming of the tricuspid valve was detected most often (all of 7 patients) in the apical 4-chamber view. In contrast, no patients without TS who had a decreased EF slope on the M-mode echocardiogram showed diastolic doming. These data suggest that a reduced DE amplitude of ≤ 10 mm associated with a decreased EF slope on the M-mode echocardiogram and diastolic doming of the tricuspid valve on the 2-D echocardiogram are useful echocardiographic signs in the diagnosis of TS.

Value of two-dimensional echocardiography in detecting tricuspid stenosis.

We reviewed the M-mode and two-dimensional echocardiograms of 100 consecutive patients with rheumatic heart disease. All were subsequently studied by cardiac catheterization and angiography. In four patients, cardiac catheterization showed tricuspid stenosis (average mean diastolic gradient 6.2 mm Hg), which was confirmed during cardiac surgery. M-mode echocardiography showed a diminished EF slope in 12 patients (mean 26 mm/sec), including the four patients with tricuspid stenosis. Seven of the eight patients without tricuspid stenosis had significant pulmonary hypertension; the reasons for the diminished EF slope in the other patient could not be identified. Tricuspid stenosis was diagnosed in four patients from two-dimensional echocardiograms on the basis of diastolic doming and restricted leaflet motion of the tricuspid valve. These four patients were the same patients in whom tricuspid stenosis was diagnosed by cardiac catheterization. We conclude that two-dimensional echocardiography is useful in the diagnosis of tricuspid stenosis.

Diagnosis of Tricuspid Stenosis by Catheterization and Noninvasive Techniques

Diagnosis of Tricuspid Stenosis by Catheterization and Noninvasive Techniques

Presystolic Click: Value of External Pulse Tracing for Recognition

High frequency clicks, arising as a consequence of valvular heart disease, are generally confined to the period of ventricular systole. Several investigators 1 Perloff JK Harvey WP Clinical recognition of tricuspid stenosis. Circulation. 1960; 22: 346-364 Crossref PubMed Scopus (32) Google Scholar , 2 Bousvaros GA Stubington D Some auscultatory and phonocardiographic features of tricuspid stenosis. Circulation. 1964; 29: 26-33 Crossref PubMed Scopus (6) Google Scholar , 3 DeBrito AHX Sekeff JAB Toledo AN et al. Early stage of tricuspid stenosis. Am J Cardiol. 1966; 18: 57-63 Abstract Full Text PDF PubMed Scopus (5) Google Scholar , 4 Killip T Lukas DS Tricuspid stenosis; physiologic criteria for diagnosis and hemodynamic abnormalities. Circulation. 1957; 16: 3-13 Crossref PubMed Google Scholar , 5 Gibson R Wood P The diagnosis of tricuspid stenosis. Br Heart J. 1955; 17: 552-562 Crossref PubMed Scopus (22) Google Scholar , 6 Yu PN Harken DE Lovejoy FW et al. Clinical and hemodynamic studies of tricuspid stenosis. Circulation. 1956; 13: 680-691 Crossref PubMed Google Scholar have described the diastolic murmur of tricuspid stenosis as “scratchy” and of higher pitch than that associated with mitral stenosis.

Reflected ultrasound in the diagnosis of tricuspid stenosis ∗

Reflected ultrasound curves, which appear to reflect movement of the anterior leaflet of the tricuspid valve, have been obtained by directing the ultrasound beam toward the spine from the fourth or fifth left intercostal space. From this projection, the tricuspid valve lies anterior and medial to the position of the mitral valve pattern. Records were obtained from 31 patients with mitral valve disease and proved normal tricuspid valves. The configuration of the tricuspid pattern is similar to that established as the normal configuration for the mitral valve movement. The velocity of movement posteriorly, after initial opening of the tricuspid valve, was 60 to 125 mm./sec. in the subjects with normal tricuspid valves. Records were obtained from 6 patients with tricuspid stenosis. In contrast to the normal tricuspid pattern, the record from these patients demonstrated a marked delay in posterior movement after opening of the valve. The velocity of motion posteriorly from peak 4 in the pattern was reduced to 8 to 30 mm./sec. Although a tricuspid valve curve is difficult to obtain from subjects with no heart disease, a satisfactory record can be inscribed from most patients with mitral stenosis. This is the patient group in which the diagnosis of tricuspid stenosis is not most important. The validity and accuracy of this method in the determination of tricuspid stenosis has been demonstreated. The ultrasounddcardiogram, which has proved of definite clinical value in the assessment of mitral value disease, therefore can be applied as a useful clinical diagnostic method for the study of tricuspid disease.

The diagnosis of tricuspid stenosis

1. 1. The blood pressure records from the right auricles and right ventricles of three patients with tricuspid stenosis are described. 2. 2. In all three the auricular blood pressure was higher than the ventricular blood pressure during ventricular diastole. This abnormal pressure gradient across the tricuspid valve appears to be a most valuable sign of tricuspid stenosis. 3. 3. Abnormally high auricular pulse pressures, which were not transmitted to the ventricle, were present in two patients with sinus rhythm. The abnormal auricular pulse pressure is manifest clinically as a giant “a” wave in the jugular phlebogram and a presystolic hepatic pulsation. 4. 4. The diagnostic importance of giant “a” waves in the jugular venous pulse of patients with mitral stenosis is discussed.