1. Tricuspid valve disease
Jeff Macemon MBChB PGDMSM
RACS Cardiothoracic Trainee
Waikato Cardiothoracic Unit

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8. Functional (Secondary) TR
RV dysfunction and Dilatation
(Usually as a consequence of Left sided disease in association with PHTN)
Tricuspid annulus dilated and fails to shorten during systole
(normally 15-20%)
Annular Dilatation along Anterior and Posterior leaflets
(Septal leaflet portion relatively fixed with the fibrous skeleton between left/right trigones)
Diameter Threashold approx. 34mm
 Failure of leaflet coaptation
Source: Kirklin/Barratt-Boyes Cardiac Surgery (Kouchoukos)

9. Source: Kirklin/Barratt-Boyes Cardiac Surgery (Kouchoukos)

10. Primary causes of Tricuspid Disease
Rheumatic Stenosis and Regurgitation
Endocarditis
Traumatic injury
Carcinoid Disease

11. Rheumatic Tricuspid Disease
In association with Mitral Rheumatic Disease +/- Aortic Rheumatic Disease
Not seen as an isolated lesion
Typically results in Regurgitant valve with varying stenosis
Rarely pure stenosis
In stenosis the annulus is typicaly larger than in Mitral stenosis, owing to the preload pressure difference between left and right sides
Diastolic gradient of 4-5mmHg indicates important stenosis

12. Tricuspid Valve Endocarditis
Associated with IVDU
Pseudomonas ++
Staph aureus +
Rarely Candida

13. Traumatic Injury of the Tricuspid Valve
Blunt, non penetrating, rapid deceleration injuries
In association with rupture of papillary muscles or chordae
Ususlly Anterior leaflet flail
Rarely due to traumatic VSD
Perforation, laceration, scarring in relation to:
PPM leads
Cryo or RFA ablation procedures
Repeated RV biopsy in transplant patients

14. Carcinoid Tricuspid Valve Disease
Failure of serotonin inactivation in the liver, eg. From hepatic metastatic disease
Carciniod Syndrome
Bronchospasm, diarrhoea, nausea, malabsorption, flushing, telangiectasia
Tricuspid, Pulmonary valve, and endocardial plaques
Mixed TS/TR

15. Tricuspid Stenosis features
Diastolic Gradient >4mmHg
Mid-diastolic, often high-pitched murmur
LLSE
Maximal on inspiration
Prominent P wave (ECG)) owing to atrial hypertrophy
Elevated a wave of CVP trace
Natural history is predominantly determined by Left sided disease

16. Tricuspid Regurgitation features
JVP shows dominant and fused c and v waves
Pansystolic, high pitched murmur
LLSE, increases on inspiration
Severe TR manifests by:
Progressive fatigue/weakness, reduced CO
Ascities, congestive hepatosplenomegaly
Peripheral oedema
Source:

17. Severe Tricuspid Regurgitation features
Vena contracta often >0.7mm
Dilation of IVC with flow reversal in hepatic veins
Maximal annular circumference 14+/-0.7cm
Cf normal 11.9+/-0.9cm
Despite these, as RV function is dynamic, features of TR are best assessed in the OR under ideal haemodynamics

18. Tricuspid Regurgitation features
Severe Functional TR is present in ~30% of patients with Mitral Regurgitation
2/3 of patients returning for Tricuspid surgery only had mild TR at the time of mitral valve surgery
The tricuspid annulus does not remodel after left sided surgery
Importance of recognising dilatation at initial surgery as this is a predictor of late TR

20. Important features of Tricuspid Surgery
Anatomical considerations
AV node
Aortic annulus, non coronary cusp
Coronary sinus
Right Coronary artery
Potential for PPM
Repair vs replacement
Choice of prosthetic device

23. Annuloplasty technique
Plication of the anterior and posterior septal portions
Reducing annular circumfrence
Effectively “bicuspidising” the valve
Band vs ring
De Vega annuloplasty