Advanced Certificate in Clinical Cardiology – Edition II

Video Transcript

Video Transcript: Tricuspid and Pulmonary Valve Disease – Part 1

Hello, today in this session, we will talk about some of the other valvular conditions, which are
encountered less frequently than the mitral and aortic valvular diseases, but still, you will
encounter them sufficiently frequently for you to have a good working knowledge of it. So, today
we will talk about the diseases affecting predominantly the right-sided valves, i.e., the Tricuspid
and the pulmonary valve.

Case Study

Let us start with a case example. There is a 32-year-old lady; let’s call her Manjula. She presents
with shortness of breath and swelling of her feet and abdomen, which has been going on for some
months now. On examination, you find a thin built women with pedal edema, ascites and we also
note prominent venous pulsations in the neck.
The main murmur you find on examination is the mid-diastolic murmur at the lower left sternal
border, which is augmented with inspiration. This case example is a little classically presented.
You may not really find this kind of a situation in real life, and we will discuss the reasons for that.

Question

So meanwhile, you need to think of a question related to this case.

So, what is likely to be true in Manjula’s condition?
a. She is likely to have multivalve disease
b. The etiology is unlikely to be rheumatic
c. This is a common presentation
d. This is more common in men
We will discuss the answer to this when we discuss the pathology.

Question

The next question I want you to think about is, if a patient has multi-valvular involvement and
he/she has significant stenosis of the Mitral, Tricuspid, as well as Aortic valves, what do you think

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should be the order of correcting these stenotic lesions. In other words, which should you do first,
and then which next, and so forth?

So, I have given you four choices. Take a good look at it.
And then, we will discuss the rationale for this again in our talk.
Tricuspid Stenosis
Let us talk about the first of the lesions, the Tricuspid stenosis. Tricuspid stenosis is almost
always, especially in our context, is going to be rheumatic in origin. We discussed in one of the
previous talks about mitral stenosis, and as to how commonly it was going to be rheumatic in our
situation. This is much even more so for Tricuspid Stenosis. You don’t encounter it commonly,
but whenever you encounter it, you can be sure that the etiology is going to be rheumatic. The
other etiologies are very very rare.
I mentioned congenital, congenital obstruction to the Tricuspid valve is much more likely to take
the form of Tricuspid atresia, which means that the valve is not at all formed. You don’t have an
opening at all on the right side. It is more likely to be Tricuspid atresia rather than a stenosis.

Carcinoid is a rare tumor and you will find that it is a recurring theme in all right-sided valvular
pathology. So, whenever you encounter any right-sided valvular pathology, you can keep carcinoid
in mind. Sometimes, you can have tumors which are obstructing the right-side AV valve and
infective endocarditis if the vegetations are big enough to cause an actual mechanical
obstruction.
TS: Hemodynamics
So, what is the hemodynamics as far as Tricuspid stenosis is concerned?
Mitral stenosis is going to produce a pressure gradient between the left atrium and left ventricle.
Similarly, Tricuspid stenosis is going to produce a gradient between the right atrium and right
ventricle. There is basically going to be a consequence of elevated RA pressure. Remember that
the right-sided flow is always augmented in inspiration because during inspiration, thoracic
pressure falls, and your venous return congestion increases to the right heart; therefore, the
gradient of Tricuspid stenosis will also be augmented in inspiration. What is the consequence of

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right atrial pressure elevation? It is going to be systemic venous congestion. In mitral stenosis,
we talked about pulmonary venous congestion. Here, the consequence is going to be systemic
venous congestion. Therefore, as a result of this fixed obstruction from RA to RV, it will manifest
as a reduction in cardiac output.
We talked about the first question, where we said that the multi-valvular disease is pretty likely.
So, the reason for this is that Tricuspid stenosis is invariably rheumatic and it hardly ever occurs
in isolation. In a person who has rheumatic tricuspid stenosis almost always they have mitral
stenosis, and they are also very likely to have Aortic valve disease. Therefore, in a patient with
Tricuspid stenosis, you are likely going to be encountering a situation, where you have a multi-
valve rheumatic involvement. So, you will hardly ever find isolated rheumatic Tricuspid stenosis.

The invariably accompanying mitral stenosis, now, in this situation, you will find that there will not
be much elevation in the pulmonary venous pressure. The reason is that there is upstream
obstruction, from the right atrium to the right ventricle, since you don’t have much blood going
through. Therefore, on the left heart also, the pulmonary venous return will be proportionately
reduced. Therefore, you could see that because of Tricuspid stenosis, the pulmonary circulation
is kind of protected from the surge of blood and therefore the symptoms of mitral stenosis could
be potentially masked by accompanying Tricuspid stenosis.
Symptoms
So, let us look at the clinical presentation. We said that ultimately the cardiac output will be on
the lower side. Therefore, one of the common symptoms is fatigue. Then there are other
symptoms predominantly related to systemic venous congestion; there is edema, there is
abdominal swelling. Accompanying mitral stenosis, there may be relatively few symptoms for the
reason we already discussed. So, whenever you find a patient with mitral stenosis, but the
symptoms of mitral stenosis, especially dyspnea, is rather masked, then you should suspect the
presence of associated Tricuspid stenosis.
Physical Findings
What would be the physical findings? You will have an elevated JVP because the right atrium is
under pressure, and this is manifested in the form of a prominent A wave in the JVP. Then you

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can find a diastolic thrill, which is at the lower left sternal border that is the area of the Tricuspid
valve, as opposed to finding a diastolic thrill at the apex, which would go more in favor of mitral
stenosis.

Similarly, you will have a mid-diastolic murmur, a low pitched rumbling murmur at the lower left
sternal border, which is increased with inspiration, which is also an important differentiation from
mitral stenosis. The diagnosis of Tricuspid stenosis clinically can be challenging because, as I
said almost always, there is accompanying mitral stenosis so you may have a low pitched mitral
stenotic murmur at the apex. Sometimes, the murmur can be pretty loud, and it can be heard in
the parasternal area. Therefore, one can be confused as to whether they are hearing two separate
mid-diastolic murmurs or whether it is just one murmur of mitral stenosis, which is been heard
over a wider area. So, looking for this augmentation and inspiration could be an especially
important finding when you have an MDM in the lower parasternal area. If it is augmented with
inspiration, then that cannot be explained by mitral stenosis.

The lungs, as I said, could be relatively clear. Remember, we talked about the pulmonary
circulation is protected by the presence of Tricuspid stenosis. Another, rather uncommon but
pathognomic finding, if you find it in Tricuspid stenosis, is the presence of hepatic pulsations,
which are presystolic rather than systolic. If you time it with your cardiac cycle, you will find that
it occurs just before the onset of systolic. Such Presystolic hepatic pulsations are very
characteristic for significant Tricuspid stenosis.
ECG
Let us look at what the investigations will show us. The ECG, as we can expect is going to display
right atrial enlargement, because the right atrium is dilating under pressure due to the obstructed
Tricuspid valve. As you can see in leap two, the tall peaked looking P wave, which is exceeding 2
millimeters in height, and the same thing you can also see sometimes in leap V1 as well, where
you can have a tall peaked looking P wave. As I said, due to invariably accompanying mitral
stenosis in this situation, you will usually have symptoms of bi-atrial or rather you will have
findings of bi-atrial enlargement on the ECG. Left atrial enlargement because of mitral stenosis

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and right atrial enlargement because of Tricuspid stenosis. So, most often, in the case of
Tricuspid Stenosis, you are going to find bi-atrial enlargement on the ECG.
Chest X-ray
What about the X-ray?
Again with severe Tricuspid stenosis, the most striking finding is going to be significant right atrial
enlargement. So, look at this X-ray which has been displayed. You can see how far out the right
heart border is shifted, and you can see the round convexity, which represents the right atrial
enlargement. Again, just like we talked about fairly clear lungs, on the physical examination, you
may find a relative lack of pulmonary congestion even if there is associated mitral stenosis.
Echocardiography
What is the echocardiography going to show?
Without going into too many details, I just want to show you the classical appearance of Tricuspid
stenosis on echocardiography. You can see the picture panel on the left, where you can see RA
as well as LA, the right and left atria, both are pretty dilated. They are bigger in size than the
concomitant ventricle, and you can see the dooming appearance of both the valves because there
is both Tricuspid stenosis and Mitral stenosis.

On the right-hand panel, you can see the color doppler, which has been portrayed. You can see
this high-pressure turbulent jet across the Tricuspid valve because of the obstruction. Normally,
there is hardly any pressure gradient between the right atrium and the right ventricle. Even as little
a gradient as two millimeters of mercury generally indicates the presence of some Tricuspid
stenosis, and any gradient exceeding 4 millimeters of mercury from the right atrium to the right
ventricle is generally considered to the severe Tricuspid stenosis. So, unlike on the left side where
we think in terms of higher gradients and pressures. The right-sided circulation is a low-pressure
circulation. Therefore, the corresponding gradients to make a diagnosis are much lower, as far as
the right AV valve is concerned.
Management
How would you manage a case of Tricuspid stenosis?

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As I said, it is generally going to come to you, in the form of a multi-valve pathology. But, because
of the presence of upstream obstruction, the first place where the venous return from the body is
going to come in, is going to be is the right heart, then from there, it is going to go to the pulmonary
circulation, the mitral valve, and then after the left ventricle to the Aortic valve. So, you can see in
a sense that the most upstream valve is the Tricuspid valve, then you have the mitral valve, then
you have the Aortic valve. So, whenever there is severe Tricuspid stenosis, you may expect that
the symptoms of systemic venous congestion predominate over the findings of mitral stenosis.
Therefore, these patients will generally benefit from diuresis and salt restriction. Due to atrial
enlargement, there can often be atrial fibrillation, and you should control the ventricular aid, which
can worsen the symptoms.

As far as the actual correction of the valvular pathology is concerned, it is usually focused on
correcting all the valvular pathologies together that’s always going to be accompanying valve
disease. So, many times if the Tricuspid stenosis is not very significant, you may not need to
individually correct it for a Tricuspid stenosis alone. Often times surgical corrections is warranted
because there are other valves, which are significantly involved.

So, if you are doing a surgery to correct other valve pathology, then you can also do a
commissurotomy for the Tricuspid stenosis. There could be also Tricuspid regurgitation which is
accompanying that, which may need an annuloplasty as well.
Now, we talked about the question where you have multiple stenotic lesions, Tricuspid stenosis,
mitral stenosis, Aortic stenosis. In such a patient, what should you correct first?
Should you open the mitral valve first? Should you Aortic valve first, then what should you do
second, and so forth.
The simple concept is that you need to correct the downstream stenosis first, because the
Tricuspid valve being the most upstream. Now suppose if you imagine without opening of the
mitral valve, without opening of the Aortic valve, if you just first relieve the Tricuspid stenosis only,
there is going to be a surge of blood now that you have received the Tricuspid obstruction, which
is going to go into the left atrium and it can precipitate acute pulmonary edema.

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Similarly, if you open the mitral valve first without opening the downstream Aortic valve with
severe Aortic stenosis, then similarly, you can have a surge of blood going into the LV but unable
to get past the Aortic valve, and again, you can precipitator hemodynamic decompensation.

So, typically, the order of correction should be downstream valves first. So open up the Aortic
valve, then open up the Mitral valve, lastly, open up the Tricuspid valve. So, this way, in the
presence of Tricuspid stenosis, you do a multi-valve correction. If at all there is a predominant
Tricuspid stenosis you open up, you do a commissurotomy. If there is accompanying Tricuspid
regurgitation, you may have to do a valvuloplasty as well.

If you are thinking in terms of a valve replacement which should be unusual in this situation, but
sometimes the Tricuspid valve is very badly distorted, there is a lot of Tricuspid regurgitation in
such rare instances the Tricuspid valve may need to be replaced and here, in the Tricuspid
position, there is a unique consideration that you almost always favor bioprosthesis over a
mechanical valve. We already said that the RA to RV the circulation is a very low-pressure
circulation therefore, the traditional degeneration of the bioprosthetic valve due to the stress of
the circulation, the risk of that is much lower or least in the Tricuspid position.

Secondly, because of this low flow situation, the risk of valve thrombosis with the mechanical
valve is much higher. Because of these considerations in the Tricuspid position, the valve of
choice is invariably of the bioprosthesis.
Lastly, we talked about balloon mitral valvotomy or (BMV) when we talked about mitral stenosis.
What about a similar balloon procedure for the Tricuspid valve?
It is hardly ever done, because usually for two reasons:
1. Usually, there is invariably Tricuspid regurgitation, which accompanies Tricuspid stenosis
in the rheumatic situation. Secondly, the presence of other multi-valve pathology generally
necessitates surgery. So, isolated percutaneous ballooning of the Tricuspid valve alone is
very, very uncommonly done.

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So, that is kind of the summary as far as the Tricuspid stenosis is concerned. Number one, it is a
less commonly encountered lesion; almost always rheumatic, usually seen in the context of the
multi-valvular pathology, and then usually, surgical correction is done for the multivalvular
pathology by correcting downstream lesions first and then the upstream lesions later.