Triscuspid valve study facts

Question 1

Signs of tricuspid regurgitation

Answer 1

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

Question 2

What are causes of Tricuspid Stenosis

Answer 2

Rheumatic fever
Carcinoid heart disease
Congenital triscupid stenosis

Question 3

What are surgical options for tricuspid valve annular dilation

Answer 3

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

Question 4

What structures are at risk during triscuspid valve surgery

Answer 4

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)

Question 5

How do you size a triscuspid valve ring

Answer 5

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

Question 6

How you place your sutures for tricuspid annuloplasty

Answer 6

Mattress sutures are placed circferentially, wider on the annulus.

avoid the AV bundle at apex of triangle of koch

Question 7

What are tricuspid surgery options for endocarditis

Answer 7

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

Question 8

What are causes of organic TR

Answer 8

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

Question 9

What are quantitative methods for measuring TR

Answer 9

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

Question 10

What is important intra-operative assess of TR

Answer 10

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

Question 11

What are risk factors for recurrence of TR

Answer 11

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

Question 12

How does carcinoid syndrome present

Answer 12

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

Question 13

What are the cardiac manifestations of carcinoid

Answer 13

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
Regurgitation
May constrict the annulus leading to stenosis

Question 14

What is management of Carcinoid syndrome

Answer 14

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

Question 15

What are other associated lesions with ebstein’s

Answer 15

rhythm disturbances including supraventricular tachycardia, ventricular tachycardia, and WPW

Question 16

What are symptoms of TR

Answer 16

dyspnea and fatigue

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

Question 17

What are signs of TR

Answer 17

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

Question 18

How is severe TS quantified

Answer 18

tricuspid valve area < 1cm2

mean tricuspid diastolic pressure gradient can also be used to quantify TS

Question 19

What are IIa indications for surgery in severe TR

Answer 19

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

Question 20

What are the surgical options for tricuspid valve annular dilation

Answer 20

DeVega annuloplasty
Right annuloplasty
Bicuspidisation/plication of the tricuspid valve

Question 21

List structures at risk during tricuspid valve surgery

Answer 21

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

Question 22

Describe a De Vega annuloplasty

Answer 22

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

Question 23

What leaflet is the smallest and biggest in tricuspid position?

Answer 23

Septal is smallest

Anterior is biggest

Question 24

How does annulus increase

Answer 24

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

Question 25

How does Marfan lead to tricuspid dysfunction

Answer 25

lead to prolapsing leaflets
elongation of chardae
chordal rupture

Question 26

What do guidelines say about pacemaker or defibrillator leads causing TR

Answer 26

Do NOT replace lead.

Makes things worse by taking it out and placing an epicardial lead.

Question 27

What are right sided heart failure signs

Answer 27

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

Question 28

What is SVG for a bioprosthetic valve in the tricuspid position

Answer 28

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)

Question 29

What is Ebstein’s anomaly

Answer 29

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