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Tricuspid Valve Diseases
M.Sahebjam M.D.
Tehran Heart Center
The forgotten valve
Tricuspid Valve Anatomy
TV annuluss
• The tricuspid valve is the most apically (or
caudally) placed valve with the largest orifice
among the four valves.
• The tricuspid annulus is oval-shaped and when
dilated becomes more circular.
• 20% larger than MV annulus .
• Normal TV annulus= 3.0 3.5 cm
• the tricuspid valve has three distinct leaflets
described as septal, anterior, and posterior.
• The septal and the anterior leaflets are larger.
• The posterior leaflet is smaller and appears to be
of lesser functional significance since it may be
imbricated without impairment of valve
• The septal leaflet is in immediate proximity of
the membranous ventricular septum, and its
extension provides a basis for spontaneous
closure of the perimembranous ventricular
septal defect.
• The anterior leaflet is attached to the
anterolateral margin of the annulus and is often
voluminous and sail-like in Ebstein’s anomaly.
Papillary Muscles & Chordae
• There are three sets of small papillary muscles,
each set being composed of up to three muscles.
• The chordae tendinae arising from each set are
inserted into two adjacent leaflets.
• the anterior set chordae insert into half of the
septal and half of the anterior leaflets.
• The medial and posterior sets are similarly
related to adjacent valve leaflets.
Etiology of Primary Tricuspid Valve
• Congenital
—Cleft valve generally in association with atrioventricular canal defect
—Ebstein’s anomaly
—Congenital tricuspid stenosis
—Tricuspid atresia
• Rheumatic valve disease, generally in association with rheumatic
mitral valve disease
• Infective endocarditis
• Carcinoid heart disease
• Toxic (eg, Phen-Fen valvulopathy or methysergide valvulopathy)
• Tumors (eg, myxoma)
• Iatrogenic—pacemaker lead trauma
• Trauma—blunt or penetrating injuries
• Degenerative—tricuspid valve prolapse
Etiology of Secondary or Functional
Tricuspid Valve Disease
• Right ventricular dilatation
• Right ventricular hypertension
• Global right ventricular dysfunction resulting
from cardiomyopathy, myocarditis, or
longstanding right ventricular hypertension with
• Segmental dysfunction secondary to ischemia or
infarction of the right ventricle, endomyocardial
fibrosis, arrhythmogenic right ventricular
Clinical Presentations
• Pure or predominant tricuspid stenosis
• Pure or predominant tricuspid regurgitation
• Mixed
Tricuspid valve disease—Symptoms
• Fatigue
• Liver/gut congestion
• Right upper quadrant discomfort
• Dyspepsia
• Indigestion
• Fluid retention with leg edema
• Ascites
Tricuspid valve disease ausculatory
• Stenosis : Low-to medium-pitch diastolic
rumble with inspiratory accentuation
• Regurgitation :Soft, early, or holosystolic
murmur Augmented with inspiratory effort
(Caravallo’s sign)
• Prolapse : Systolic click
• Substantial tricuspid regurgitation may exist
without the classic ausculatory findings. Thus,
clinical evaluation including cardiac auscultation
cannot be used to exclude tricuspid valve
Transthoracic Views
Transesophageal Views
Transesophageal Views
Key Diagnostic Features
• Mild TR is seen in up to 60% and Moderate TR
in up to 15% of healthy individuals.
• Mild or worse TR in a valve with thin leaflets,
normal coaptation, and normal-appearing
supporting structures, suggests regurgitation
is physiologic or functional .
Key Diagnostic Features
• In carcinoid disease, the leaflets are thickened
and retracted with a fixed orifice usually leading
to predominant regurgitation and less severe
• Approximately 30% of patients with MVP have
redundancy and prolapse of the tricuspid valve,
leading to TR.
TR & TS Severity
PAP based on TR Velocity
• Mild increased PAP = 2.6 - 2.9 m/s (27-33 mmhg)
• Moderate increased PAP = 3.0 - 3.9 m/s (36-60
• Severe increased PAP = 4.0≤ (64 mmhg ≤ )
Tricuspid Valve Stenosis
1/The normal tricuspid inflow velocity is less than 0.5
to 1 m/s, with a mean gradient less than 2 mm Hg.
2/The evaluation of tricuspid valve stenosis with
Doppler echocardiography is similar to the
method described for mitral stenosis , although the
constant of 190 has been proposed of the PHT
method .
3/Tricuspid stenosis is considered severe when the
mean gradient is 7 mm Hg or more and PHT is 190
milliseconds or longer.
Key Diagnostic Features
• TS can be missed on routine TIE because the
degree of leaflet thickening may appear subtle,
even with significant TS.
• Planimetry of the tricuspid valve orifice by
two-dimensional images is difficult and unreliable.
• A pressure half-time ~ 190 msec suggests severe TS
• Valve area is less often used for determining
TS severity, but an area < 1.3 to 1.5 cm2 is
generally considered significant enough to
cause symptoms.
European Guideline for TV managment
AHA/ACC Guideline for TV managment