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Signs of tricuspid regurgitation

Increased jugular venous pressure with a prominent V wave
Peripheral edema and ascites
Pan-systolic murmur prominent at the left sternal edge, increased with inspiration
3rd hear sound (gallop rhythm)
Right ventricular heave
Jaundice secondary to hepatic congestion in severe TR


What are causes of Tricuspid Stenosis

Rheumatic fever
Carcinoid heart disease
Congenital triscupid stenosis


What are surgical options for tricuspid valve annular dilation

De Vega annuloplasty
Ring annuloplasty
Bicuspidisation/plication--running suture along the posterior TV annulus to shorten or eliminate the posterior leaflet resulting in a bicuspid valve


What structures are at risk during triscuspid valve surgery

Coronary sinus
Right coronary artery
Atrioventricular nodal artery
aortic valve (non-coronary cusp)
Bundle of HIS (at the apex of the triangle of koch)
Atriventricular node (at the center of the triangle of koch)


How do you size a triscuspid valve ring

Based on the length of the base of the septal leaflet (intertrigonal length)


How you place your sutures for tricuspid annuloplasty

Mattress sutures are placed circferentially, wider on the annulus.

avoid the AV bundle at apex of triangle of koch


What are tricuspid surgery options for endocarditis

Tricuspid excision
if pulmonary pressure are not elevated
if endocarditis is very extensive
in IV drug abusers where the dependence is not controlled
Tricuspid valve replacement
Limited valve excision and repair
replacement with homograft


What are causes of organic TR

Carcinoid heart disease
Post radiation
Diet drug heart disease
pace maker/AICD didease


What are quantitative methods for measuring TR

ERO > 0.4cm2
regurgitant volume > 45ml/beat
Vena contracta > 0.7 cm
Systolic flow reversal in hepatic veins


What is important intra-operative assess of TR

measure the annular assessment. Recurrent if septal anterior annulus is > 7- mm


What are risk factors for recurrence of TR

No ring used
severe of baseline TR
residual TR at first OR
Persistent pulmonary hypertension
residual left sided lesions


How does carcinoid syndrome present

Related to inappropriate and excessive release of serotonin and bradykinin
Hot flashes
Violacious skin changes


What are the cardiac manifestations of carcinoid

50% develop valve disease
Primary lesion is located in the small intestine
Mainly right sided lesion
Usually TR or TS
plaques are on the downstream of the valves leading to adherence of the leaflet on the underlying structures
May constrict the annulus leading to stenosis


What is management of Carcinoid syndrome

Tricuspid valve is replaced
Pulmonary valve is valvectomy
Octreotide perioperatively
to manage vasodilatio related to release of hormones


What are other associated lesions with ebstein's

rhythm disturbances including supraventricular tachycardia, ventricular tachycardia, and WPW


What are symptoms of TR

dyspnea and fatigue
peripheral edema and ascites due to back pressure on the systemic venous circulation


What are signs of TR

increased jugular venous pressure with prominent v wave
peripheral edema and ascites
janudice secondary to hepatic congestion in severe TR
3rd heart sound
right ventricular heave
pan-systolic murmur prominent at the left sternal edge, increased with inspiration


How is severe TS quantified

tricuspid valve area < 1cm2
mean tricuspid diastolic pressure gradient can also be used to quantify TS


What are IIa indications for surgery in severe TR

tricuspid annulus size > 40 mm,
right ventricular function and size
pulmonary hypertension size > 50 mmHg at rest and 60 mmHg on exercise
right atrial size and the presence of atrial fibrillation


What are the surgical options for tricuspid valve annular dilation

DeVega annuloplasty
Right annuloplasty
Bicuspidisation/plication of the tricuspid valve


List structures at risk during tricuspid valve surgery

Coronary sinus
Right coronary artery
aortic valve (non-coronary cusp)
atriventricular nodal artery
atrioventricular node


Describe a De Vega annuloplasty

two arms of a running suture weaving along the TV annulus from the anteroseptal to posteroseptal commissure. First arm starts at the anterorspetal commiusre and goes clockwise to the posteroseptal commissure(secured with a teflon suture) and then weaved back counter clockwise.

tied over a hagar dilator


What leaflet is the smallest and biggest in tricuspid position?

Septal is smallest
Anterior is biggest


How does annulus increase

The circumference of the annulus lengths primarily onlg the attachmets of the anterior and posterior leaflet.

Septal leaflet is fixed between the fibrous trigones--preventing it from lengthening


How does Marfan lead to tricuspid dysfunction

lead to prolapsing leaflets
elongation of chardae
chordal rupture


What do guidelines say about pacemaker or defibrillator leads causing TR

Do NOT replace lead.
Makes things worse by taking it out and placing an epicardial lead.


What are right sided heart failure signs

congestive heptosplenomegaly
pulsatile liver
pleural effusions
and periheral edema
Late stages
a. wasted pts with cachexia, cyanosis, and jaundice, and hepatic cirrhosis.


What is SVG for a bioprosthetic valve in the tricuspid position

Longer duration of freedom from SVD compared to mitral
18 years 63% freedom from SVD
always possible to place a large (27 have no problem)


What is Ebstein's anomaly

Dysplasia of the tricuspid valve leaflets resulting in
1) fused, perforated or absent leaflets with abnormal chordae
2) apical displacement of the septal leaflet into the body of the right ventricle
3) a thin atrialised portion of the right ventricle
4) severe right ventricular dysfunction and dilation
5) tricuspid regurgitation
6) right ventricular outflow tract obstruction causes by displaced leaflets

Associated with rhythm disturbances including supraventricular tachycardia, ventricular tachycardia and WPW

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