Tricuspid Valve

Question 1

What are the causes of tricuspid regurgitation (TR)?

Answer 1

• Normal leaflet motion - annular dilation (secondary to pulmonary hypertension, right ventricular failure, mitral valve disease), infective endocarditis.
• Excessive leaflet motion - myxomatous degeneration.
• Restricted leaflet motion - rheumatic fever, Ebstein’s anomaly.

Question 2

How is tricuspid stenosis quantified by echocardiography?

Answer 2

• According to the AHA guidelines, the main criteria is a tricuspid valve area (TVA) <1cm2 for severe TS.
• The TVA can be calculated by the continuity equation or planimetry.
• The mean tricuspid diastolic pressure gradient can also be used to quantify tricuspid stenosis.
• Significant stenosis of the tricuspid valve may be present with a mean gradient of 3 to 5 mm Hg and an end-diastolic gradient of 1 to 3 mm Hg.

Question 3

What are the indications for tricuspid valve surgery in the absence of mitral valve disease?

Answer 3

• Class IIa - severe TR in symptomatic patients.
• Other considerations include:
• Tricuspid valve annulus size (>40mm) on ECHO
  
  • intraoperative diameter greater than 70 mm (

maximal stretched orifice from the anteroseptal to anteroposterior commissures. )

• Right ventricular function and size
• Pulmonary hypertension (>50mmHg at rest, 60mmHg on exercise),
• Right atrial size and the presence of atrial fibrillation.

Question 4

Quantification of tricuspid regurgitation based on regurgitant jet?

Answer 4

Semiquantitative evaluation of the severity of tricuspid regurgitation is based on the degree of penetration of the regurgitant jet into the right atrium.

• A jet that penetrates 2 cm into the right atrium indicates mild regurgitation.
• A jet that penetrates 3 to 5 cm is considered moderate regurgitation;
• If it is accompanied by systolic flow reversal of hepatic or caval veins, it is considered severe regurgitation.

Question 5

Quantification of tricuspid regurgitation based on PISA -proximal isovelocity surface area.

Answer 5

• A radius of 1 to 4 mm indicates mild regurgitation;
• 5 to 8 mm indicates moderate regurgitation; and
• Greater than 9 mm indicates severe regurgitation.