Makindo Medical Notes

Related Subjects: |Pulmonary Stenosis |Pulmonary Regurgitation |Pulmonary Hypertension |Tricuspid Stenosis |Pulmonary Embolism

📖 About

• Tricuspid Stenosis (TS) = narrowing of the tricuspid valve → impaired right ventricular filling & ↓ cardiac output.
• Commonly associated with other rheumatic valve lesions, especially mitral stenosis. ⚠️
• More common in females 👩‍⚕️ and often secondary to rheumatic fever.
• Left-sided symptoms may dominate, delaying recognition of TS.

🧬 Causes

• Rheumatic Heart Disease – most common; fibrotic thickening & fusion of leaflets. ❤️‍🔥
• Carcinoid Syndrome – serotonin-induced fibrosis of right heart valves. 🧪
• Congenital Tricuspid Disease – rare. 👶
• Right Atrial Myxoma – benign tumour obstructing the valve. 🎭

🩺 Clinical Features

• Right-sided heart failure signs:
  • Fatigue, ↓ exercise tolerance 🏃
  • Peripheral edema 🦶
  • Ascites 💧
• Jugular Venous Pulse (JVP):
  • Large “a” wave (unless AF present) 📈
  • Slow “y” descent ⏬
• Heart sounds & murmur:
  • Loud S1 🔊
  • Low-pitched mid-diastolic murmur (MDM) with pre-systolic accentuation.
  • ↑ with inspiration = Carvallo’s sign 🎵
• Other signs: Pulsatile hepatomegaly, jaundice, edema, ascites, atrial fibrillation ⚡

🔍 Investigations

• ECG – tall P waves in lead II (>3mm) = right atrial enlargement (P pulmonale). 📊
• CXR – enlarged right atrium (RAE). 🩻
• Echocardiography – diagnostic gold standard:
  • Restricted tricuspid leaflets
  • RA enlargement
  • Valve gradient & area calculation

🫀 Pathophysiology

• Normally: tricuspid valve allows RA → RV filling in diastole.
• In TS: narrowed valve → ↑ RA pressure → RA enlargement → systemic venous congestion.
• Results in right-sided heart failure with edema, ascites, hepatomegaly. ⚠️

💊 Management

• Medical:
  • Diuretics + salt restriction for fluid overload 💧
  • Anticoagulation (warfarin) if AF present ⚡
• Surgical:
  • Tricuspid valvotomy – in mild-moderate TS ✂️
  • Valve replacement – in severe, calcified or fibrotic valves ⚙️

📚 References

• AHA Guidelines – Valvular Heart Disease
• ESC Guidelines – Valve Disease

Cases — Tricuspid Stenosis (TS)

• Case 1 — Rheumatic TS in Middle-Aged Woman 🌍: A 48-year-old woman from India presents with progressive fatigue, ankle swelling, and abdominal distension. Exam: giant ‘a’ waves in JVP, hepatomegaly, ascites, and a mid-diastolic murmur at the left lower sternal edge, louder on inspiration. Diagnosis: Rheumatic tricuspid stenosis. Management: Diuretics for right heart failure; anticoagulation if AF; surgical repair or replacement in severe symptomatic cases.
• Case 2 — Carcinoid Syndrome with TS 🦐: A 62-year-old man with flushing, diarrhoea, and bronchospasm develops right heart failure. Echo: thickened, immobile tricuspid valve leaflets with restricted opening; 24-hour urinary 5-HIAA elevated. Diagnosis: Tricuspid stenosis due to carcinoid heart disease. Management: Treat underlying carcinoid (somatostatin analogues, tumour control); valve replacement if severe symptomatic stenosis.
• Case 3 — Congenital TS in Young Adult 👶: A 19-year-old woman with a history of congenital heart disease presents with exertional fatigue and hepatomegaly. Exam: diastolic murmur at left lower sternal edge, giant ‘a’ waves in JVP. Echo: dysplastic tricuspid valve with stenosis. Diagnosis: Congenital tricuspid stenosis. Management: Regular follow-up; surgical correction if symptomatic and severe; endocarditis prophylaxis if prosthetic valve used.

Teaching Commentary 🧠

Tricuspid stenosis is rare, usually secondary to rheumatic fever or carcinoid heart disease. - Features: Right heart failure (hepatomegaly, ascites, oedema), giant ‘a’ waves, diastolic murmur at LSE that increases with inspiration. - Diagnosis: Echocardiography confirms valve thickening and gradient. - Management: Diuretics relieve congestion; definitive therapy is surgical repair or valve replacement. Always check for concurrent left-sided valve disease in rheumatic cases (mitral involvement is common).