Tricuspid Valve

Question 1

TV views and anatomy

Answer 1

Septal leaflet in close proximity to AV

ME4C — anterior/posterior leaflet lateral, septal leaflet medial
•push probe in to CS to see posterior leaflet
•pull probe out to LVOT to see anterior leaflet

ME RV inflow-outflow — posterior leaflet lateral, anterior/septal closest to AV

TG Mid Papillary SAX — posterior leaflet near field, anterior leaflet far field, septal leaflet medial

TG RV inflow — posterior leaflet near field, anterior/septal far field (most likely anterior)

Question 2

Tricuspid Regurgitation Etiology

Answer 2

Normal valve leaflets = Functional/Secondary — 90%
•most common in adults
•RV pressure or volume overload
•annular dilation
•papillary muscle dysfunction
•PA catheter — mild TR

Abnormal valve leaflets = Structural/Primary — 10%
•Rheumatic — also involvement of MV and/or AV
Most common cause of TS, but more likely to cause TR
Most often affects: MV; MV + AV; MV+AV+TV (20-30%); AV alone (<5%, rare)
•Myxomatous degeneration
•Ebstein’s anomaly
Anterior leaflet — large, ‘sail-like’, attaches to TV annulus, funnel-shaped, incompetent
Apical displacement of small septal and posterior leaflets
Atrialization of part of RV
Associated with: secundum ASD, WPW, and VT
•Carcinoid
Only effects right side of heart since inactivated by MAO in lungs unless large tumor burden or PFO
Metastatic carcinoid —> serotonin (most common and most likely to damage leaflets), bradykinin, histamine, prostaglandins
RV valves damaged — thickened and fixed in systole and diastole with stenosis most common
Carcinoid syndrome: thickening and fibrosis of TV and PV [consider when both effected] and causes TR, TS, PR, PS with TR > TS
•Endocarditis (IVDU)

Question 3

Grading of TV regurgitation

Answer 3

CWD jet density
•very dense

Jet area
•>10 cm^2

Vena contracta
•>7 mm

Hepatic venous flow
•systolic reversal
•any increase in atrial pressure leads to a decrease in HVF due to no valves present
•atrial contraction (CVP ‘a’ wave) —> increase RAP —> decrease/retrograde HVF ‘A’ wave
•systolic contraction (CVP ‘x’ wave) —> atrial relaxation —> descent in RAP —> increase HVF ‘S’ wave
•severe TR —> CVP large ‘CV’ wave —> HVF large downward ‘S’ wave combining with ‘A’ and ‘V’ waves creates a sinusoidal pattern due to holosystolic flow reversal

TV annular size
• > 4 cm during diastole in ME4C should consider ring during left sided valve surgery

Doppler inflow
•E < A —> can’t have severe TR
•E > 1 m/s consider poor diastolic function or significant TR

Question 4

Tricuspid valve stenosis

Answer 4

Rare because the TV annulus is pretty large

Etiology: 
•Rheumatic (most common cause of TS)
Usually causes TR instead of TS
•Carcinoid
Due to serotonin damaging the valve
•Congenital abnormalities

Usually graded using peak and mean velocities / gradients
•normal peak TV velocity = 30 - 70 cm/s
•mean peak gradient > 5 mmHg = severe TS

Remember gradients depend on HR and flow
•HR increase —> decrease diastolic filling time —> increase gradient
•decrease flow —> decrease gradient