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Echocardiography The role of echocardiography in the evaluation of the tricuspid valve is

discussed in detail elsewhere but the major findings in tricuspid stenosis will be summarized here.
(See "Echocardiographic evaluation of the tricuspid valve", section on 'Tricuspid stenosis'.)
Echocardiographic features of tricuspid stenosis include limited mobility of the leaflets, reduced
separation of the leaflet tips, a reduction in the diameter of the tricuspid annulus, and diastolic
doming of the valve. Although leaflet thickening is seen, the degree of thickening and calcification is
generally less pronounced than in rheumatic mitral stenosis.
Doppler echocardiography reveals high velocity turbulent diastolic flow across the stenotic orifice
and prolonged pressure half-time. A tricuspid valve area less than 1.0 cm 2 indicates severe tricuspid
stenosis [13].
It is important to assess the presence and severity of tricuspid regurgitation, since this can influence
the decision to proceed with balloon valvotomy. (See'Patient selection for valvotomy' below
and "Echocardiographic evaluation of the tricuspid valve".)
Cardiac catheterization Right heart catheterization is performed with two catheters or one
double lumen catheter. After calibration of the two transducers, it is important to first document
identical simultaneous recordings of right atrial pressure and then to advance one of the catheters
into the right ventricular cavity. Simultaneous recordings of atrial and ventricular pressure are made
in at least 8 to 10 cardiac cycles. Diastolic pressure gradients as low as 2 to 6 mmHg are common
in severe tricuspid stenosis; gradients rarely exceed 10 mmHg. Thus, respiratory variation of a
relatively low pressure gradient or non-simultaneous measurements may provide misleading data. A
single catheter "pull-back" from the ventricle to the atrium does NOT provide a sufficiently accurate
measurement of the pressure gradient. (See"Hemodynamics of valvular disorders as measured by
cardiac catheterization".)
Cardiac output is measured using the Fick principle for oxygen, and the valve area is calculated
similarly to the mitral valve area. A tricuspid valve area less than 1.0 cm 2 indicates severe tricuspid
stenosis [13]. (See "Hemodynamics of valvular disorders as measured by cardiac catheterization",
section on 'Mitral valve gradient'.)
PATIENT SELECTION FOR VALVOTOMY Patients with signs and symptoms of systemic
venous hypertension and congestion should be considered for balloon valvotomy. Transvalvular
pressure gradients as low as 3 mmHg and valve areas less than 1.5 cm 2 can indicate serious, but
treatable, stenosis. Tricuspid regurgitation that is greater than mild is generally thought to be a
contraindication to valvotomy, but a few patients with moderate regurgitation have been
successfully treated with this technique. Tumor masses, vegetations, and thrombi are
contraindications to valvotomy.
Pregnancy It is not infrequent that signs and symptoms of rheumatic heart disease first occur
during pregnancy, when the cardiac output increases because of the rise in blood volume and heart
rate. (See "Renal and urinary tract physiology in normal pregnancy".)
There is little experience with balloon valvotomy during pregnancy, but it appears to be effective in
patients with refractory systemic venous congestion. Isolated balloon tricuspid valvotomy and
concurrent balloon valvotomy of mitral and tricuspid valves have been successfully performed
during pregnancy [14,15]. Great care must be taken to limit radiation exposure.

RESULTS OF BALLOON VALVOTOMY There is far less experience with tricuspid valvotomy
than with mitral valvotomy. Valve areas generally increase from less than 1 to almost 2 cm 2. While
some stenosis persists, this change in area is sufficient to produce a significant reduction in the
transvalvular pressure gradient and a decrease in right atrial pressure.

In a report of four patients, tricuspid valvotomy, performed with two balloons, produced a
rise in valve area from a mean of 0.8 to 1.8 cm 2[16]. There was no increase in the severity
of tricuspid regurgitation. Follow-up at 8 to 20 weeks showed persistence of the early
beneficial effects; valve area was 1.9 cm2 and cardiac output was significantly higher at rest
and during exercise. Symptomatic improvement was reported in all four patients.

Another study evaluated the use of one, two, and three balloons to perform valvotomy [17].
The single patient treated with one balloon did not show improvement, but the three treated
with two balloons and the one treated with three balloons all exhibited significant
improvement in valve area and symptoms without increase in tricuspid regurgitation. The
authors concluded that the combined use of two balloons (23 to 25 mm) are adequate for
most patients. Later experience with the Inoue balloon indicated that single balloon
techniques may be as effective as the previous double balloon techniques [18].

Similar beneficial results have been described when balloon valvotomy is used to treat combined
mitral and tricuspid stenosis, as well as in cases of combined aortic, mitral, and tricuspid stenosis
[19,20].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
Basics and Beyond the Basics. The Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who want a general overview and
who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10 th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on patient info and the keyword(s) of interest.)

Basics topics (see "Patient information: Tricuspid stenosis (The Basics)")

SUMMARY AND RECOMMENDATIONS Recognizing that there are no published studies that
compare percutaneous balloon valvotomy with surgical valvuloplasty, and that only limited long-term
results have been published [19], limited conclusions are appropriate. The available data indicate
that balloon valvotomy for tricuspid stenosis is effective and is associated with a low morbidity.
Thus, if symptoms of systemic venous hypertension and congestion are not adequately controlled
with diuretics and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor
antagonists, balloon valvotomy of the stenotic tricuspid valve should be performed. Surgical
correction of the stenotic lesion is indicated in patients whose valve is not treatable with balloon
techniques

Two-dimensional echocardiography Two-dimensional (2-D) transthoracic echocardiography or


transesophageal echocardiography [9] enables identification of the specific features of tricuspid
stenosis. Similar to mitral stenosis, the hallmark for the diagnosis is doming of the tricuspid valve
seen in the parasternal long-axis view or in the apical four-chamber view. Other 2-D
echocardiographic findings include thickened, distorted, and calcified leaflets and restrictive leaflet
motion [10].
Doppler echocardiography We agree with the 2014 American
HeartAssociation/American College of Cardiology Valvular Heart Disease guidelines, which classify
a tricuspid valve with mean pressure half-time 190 ms or a valve area 1.0 cm 2 as being severely
stenotic [10]. The tricuspid gradient is highly variable depending upon heart rate, stroke volume,
and phase of the respiratory cycle, though severe tricuspid stenosis is usually associated with a
mean pressure gradient of 5 to 10 mmHg at a heart rate of 70 bpm.
Recordings for tricuspid stenosis are similar to those seen for mitral stenosis: There is turbulent
diastolic inflow, higher-than-normal maximal flow during diastole, and an increased pressure halftime. The mean tricuspid diastolic gradient can be estimated from the tricuspid inflow time velocity
integral by applying the modified Bernoulli equation.
Estimating tricuspid valve area using echocardiography is not as well-established as estimating
mitral valve area. Methods for calculating mitral valve area, such as pressure half-time, the
continuity equation, and proximal isovelocity surface area, can be applied to the tricuspid valve.
Tricuspid valve area in cm2 may be estimated as 190 divided by the pressure half-time [11].

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