Tricuspid Valve Disease

View TSDA Curriculum Online for this topic

1. Pathology

Congenital

AV canal

VSD

Ebstein's

Myxoma

2. Acquired

Structural	Functional
Rheumatic disease Endocarditis Carcinoid	Cor-pulmonale Inferior MI Left-sided lesion

Tricuspid Valve

3. Normal Anatomy

Septal, posterior and anterior leflets

Annulus- sphincter-like function

Septal annulus- fixed

Dilatation only in anterior and posterior annulus

4. Functional Incompetence of the Tricuspid Valve

Most common form of tricuspid dysfunction

No leaflet or subvalvular abnormality

RV dilatation (secondary to left-sided lesion)

RV volume overload

Pulmonary hypertension- "Pop-Off" safety feature

5. Rheumatic disease

Functional TR due to left-sided lesion

Structural- never isolated

Stenosis- rare

Mixed- stenosis/regurgitation

Most common cause for tricuspid replacement

6. Endocarditis

Usually IV drug abusers

Pseudomonas/ Staph. Aureus

Gram negatives, fungal

TR, septic pulmonary emboli

Antibiotics highly successful

7. Clinical-- Tricuspid stenosis

Prominent jugular "a-wave" or atrial fibrillation

+/- systolic murmur

Enlarged liver

Right atrial enlargement

Cath >4mm enlargement

8. Clinical-- Tricuspid regurgitation

Cannon waves in jugular pulse

Pansystolic murmur

Pulsatile hepatomegaly/ascites/edema

Catheterization- not accurate

Echocardiography

Reversal of flow in IVC

Paradoxical atrial septal shift

Annular dilatation

Intraoperative- digital exam

9. Indications for Surgery

Tricuspid stenosis

Gradient > 4 mmHg

Commissurotomy vs replacement

Tricuspid regurgitation

Clinical decision- improvement with repair of left-sided lesion

Moderate to severe TR or any structural TR

RV volume overload

Right-sided heart failure

Repair vs replacement

Endocarditis

Severe TR

Persistent sepsis

Recurrent PE

Excision vs replacement vs repair

10. Repair

Ring annuloplasty

Shorten anterior-posterior annulus

Avoid septal annulus

Sewn annuloplasty

Kay

DeVega

Can be done after cross-clamp removal

11. Replacement

Bioprosthetic valve if >/= 28 mm

Smaller annulus consider prosthetic valve

Septal sutures in base of leaflet

Epicardial permanent pacemaker electrodes

12. Excision

If IV drug abuser ceases abuse

Second-stage replacement

13. Results

Annuloplasty

Addition adds minimal risk to MVR

Freedom from moderate/severe TR about 85% for 6 years

Results poorer with pulmonary hypertension

Reoperation for TR recurrence- rare

Replacement

Early mortality 7%

Porcine valve longer life than mitral position

Thrombosis: bileaflet < disc < ball/cage

Mortality- multi-vavle-disease, EF, co-morbidities

Excision

Early mortality 12%

Survival 63% at 15 years

50% right sided heart failure

RV overload, septal shift, arrhythmias

14. Complications

Annuloplasty failure- related to pulmonary hypertension

Bioprosthetic calcification in younger age

Complete heart block

10% with MVR and TR early postoperatively

25% at 10 years

Rare after repair

15. Risk of premature death

Excision

Prior valve surgery

Older age at operation

Preoperative functional class