Introduction

• Speaker: Sophie Offin, cardiologist, PhD candidate on tricuspid valve disease at Royal Prince Alfred Hospital.

• Main focus: Tricuspid and pulmonary valves, including anatomy, clinical features, investigations, and management aspects.

Anatomy

• Heart valve overview:

  • Pulmonary Valve:

  • Tri-leaflet semilunar valve with three cusps and fibrous annulus.

  • Separation of right ventricular outflow tract from pulmonary trunk.

  • No fibrous continuity between pulmonary valve and tricuspid valve.

  • Tricuspid Valve:

  • Largest heart valve, three leaflets:

    • Anterior leaflet (largest).

    • Septal leaflet (smallest).

    • Posterior leaflet.

  • Fibrous annulus around it, with the right coronary artery coursing around.

  • Leaflets attached via chordae tendineae to papillary muscles (less defined than mitral valve).

Tricuspid Regurgitation

Classification

• Primary Causes: Intrinsic valve abnormalities, includes:

  • Congenital abnormalities (e.g., Ebstein's anomaly: apical displacement of septal and posterior leaflets).

  • Iatrogenic causes (e.g., pacemaker or defibrillator leads perforating leaflets).

  • Rheumatic valvular causes, carcinoid, infective causes (e.g., endocarditis).

• Secondary Causes (Functional Regurgitation):

  • Normal leaflets with:

  • Annular dilatation and caudal retraction/stretch.

  • Volume overload from conditions like right ventricular infarction, pulmonary hypertension, or left ventricle dysfunction.

• Isolated Tricuspid Regurgitation (Atrial Functional):

  • Due to severe right atrial dilatation leading to annular dilatation, often in chronic atrial fibrillation.

Symptoms and Clinical Presentation

• Symptoms typically present late due to relative asymptomatic periods.

• Consequences of tricuspid regurgitation:

  • Regurgitant flow leads to elevation in right atrial pressures and systemic venous congestion:

  • Dependent edema.

  • Early satiety.

  • Right ventricular failure:

  • Inadequate forward flow resulting in breathlessness, exercise intolerance, and fatigue.

• Clinical examination findings:

  • Pathognomonic pansystolic murmur (can be soft/absent in severe cases due to equalization of pressures).

  • Right ventricular heave due to dilatation.

  • Jugular venous distension with elevation and ‘v’ waves due to systolic regurgitation.

  • Systemic symptoms: hepatomegaly, ascites, peripheral edema.

Investigations

• Primary Investigation: Echocardiography (transthoracic and transesophageal):

  • Transthoracic echo is often preferable due to the anterior location of the tricuspid valve.

  • Assessing etiology and severity of tricuspid regurgitation:

  • Determine if intrinsic (primary) or secondary (normal leaflets).

  • Severity assessment using:

    • 2D Doppler and color Doppler.

    • Vena contracta width to measure regurgitant jet width.

  • Consequences visible in echocardiography:

  • Annular, right ventricular, and right atrial dilatation, as well as right ventricular dysfunction.

• Other imaging options:

  • Cardiac CT for assessing annular size and evaluating annularity before interventions.

  • Cardiac MRI for advanced assessment of right ventricular function and volumes.

Prognosis and Management

• Tricuspid regurgitation previously thought of as benign but now recognized for its poor prognosis:

  • Stepwise progression of worsening prognosis with increasing severity (from none to severe) independent of ventricular functions.

• Surgical interventions:

  • Surgery for isolated tricuspid valve regurgitation is infrequent with high mortality rates.

  • Challenges include diverse etiologies and patients often remaining asymptomatic until late stages.

• Management Approaches:

  • Diuretics for severe tricuspid regurgitation and right heart failure to treat volume overload.

  • Surgical guidelines advocate for tricuspid valve repair during left-sided valve surgeries for functional tricuspid regurgitation if annular dilatation >40 mm.

  • Emerging transcatheter interventions for high-risk surgical patients despite limited evidence.

Surgical Options

• Repair: Preferred where possible, particularly for secondary (functional) tricuspid regurgitation:

  • Annuloplasty devices for cinching the dilated annulus, potentially with leaflet repair.

• Replacement: More common in primary regurgitation with abnormal leaflets:

  • Usually involves bioprosthetic valves.

• Transcatheter Options: Includes:

  • Transcatheter tricuspid valve replacement, valve-in-valve techniques, ring annuloplasty, coaptation devices (based on Alfieri repair).

  • Early trials show promise for symptom improvement and reduced hospitalization, but more extensive studies needed.

Tricuspid Stenosis

• Etiology: Rare and often presents with tricuspid regurgitation, commonly rheumatic in nature.

• Symptoms result from elevated right atrial pressure and limited forward flow causing:

  • Breathlessness on exertion, fatigue.

• Echocardiographic assessment for valuation:

  • Features of stenosis visible via Doppler showing elevated gradients and reduced valve area.

Pulmonary Valve Disease

• Incidence and Etiology:

  • Congenital pulmonary valve disease more common than acquired.

  • Can present as isolated or as part of multi-system heart diseases.

• Conditions:

  • Pulmonary stenosis:

  • Usually treated in childhood via balloon valvotomy or surgery, excellent prognosis.

  • Can present as suvalvular or supravalvular stenosis, significant in conditions like tetralogy of Fallot.

  • Pulmonary regurgitation (primary and secondary):

  • Severe pulmonary regurgitation leads to right ventricular volume overload and dysfunction, often associated with congenital heart disease.

  • Secondary can arise from severe pulmonary hypertension or post-repair of stenosis.

• Treatment Options:

  • Melody valve as a percutaneous option for previously operated patients requiring repeated surgeries.