TS/TR

Question 1

What attaches the tricuspid valve to the RV?

Answer 1

A large anterior papillary muscle attaches the anterior and posterior leaflets to the anterolateral RV wall + chordal attachment to a septal papillary muscle attaches the septal and anterior leaflets to the interventricular septum

Question 2

What is the largest cardiac valve?

Answer 2

The tricuspid valve

Question 3

What is the most common cause of tricuspid stenosis?

Answer 3

Rheumatic heart disease

Question 4

What are less common causes of tricuspid stenosis?

Answer 4

Carcinoid syndrome, endomyocardial fibrosis, RA tumors, endocarditis, congenital TS, atypical Ebstein’s anomaly

Question 5

What valve area and mean gradient across the tricuspid valve do you start getting symptomatic TS?

Answer 5

Valve area < 1.5 cm2 + mean gradient ~3 mmHg

Question 6

When does TS require surgical intervention?

Answer 6

If mean gradient > 5 mmHg or valve area < 2 cm2

Question 7

What are the hemodynamic goals of TS?

Answer 7

Maintain/increase preload + maintain sinus rhythm + maintain SVR/PVR and maintain contractility

Question 8

What are the operative mortality rates after TV surgery? What is a common complication?

Answer 8

~10% operative mortality; AV block can occur due to sutures near the anteroseptal commissure

Question 9

What are primary tricuspid diseases that cause TR?

Answer 9

Rheumatic valve disease + Ebstein anomaly + myxomatous changes (connective tissue disorders) + endocarditis + carcinoid + radiation + blunt chest trauma + iatrogenic (PPM)

Question 10

What are secondary causes of functional TR?

Answer 10

Dilation of TV annulus (atrial fibrillation) + leaflet tethering due to RV dilation (i.e. pulm HTN) + left-sided cardiac abnormalities associated with TR

Question 11

What do you see on CVP tracing with TR?

Answer 11

Large v-waves

Question 12

What is Stage B TR?

Answer 12

Mild TR with no hemodynamic consequences or symptoms

Question 13

What is Stage C TR?

Answer 13

Asymptomatic severe TR with dilated RV/RA but no symptoms outside of elevated venous pressures

Question 14

What is Stage D TR?

Answer 14

Symptomatic severe TR with dilated RV/RA and symptoms like dyspnea on exertion, fatigue, ascites, and edema

Question 15

What happens after TV replacement/repair in isolated TR?

Answer 15

You can have possible relative tricuspid stenosis -> the RV has no pop off with TR and must eject all the volume through the PV -> can be put under stress and fail

Question 16

What are risk factors for TR progression?

Answer 16

Tricuspid annular dilation (>70 mm diameter) + RV dysfunction/remodeling + leaflet tethering height + pulmonary arterial HTN + Afib + intra-annular RV pacemaker leads

Question 17

What is a class I indication for TV surgery for TR?

Answer 17

Severe TR (Stages C or D) in patients with right heart failure who are getting left-sided heart surgery at the same time

Question 18

What are class IIa indications for TV surgery for TR?

Answer 18

Severe TR (stages C or D) in patients with Right heart failure with primary TR/secondary TR with annular dilation without pulmonary arterial HTN or left-sided disease + progressive TR (Stage B) at the same time of left-sided cardiac surgery with annular dilation or prior right heart failure