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Tricuspid Valve Disease

Tricuspid Valve Disease

1. Pathology

A. Congenital
1) AV canal
2) VSD
3) Ebstein's
4) Myxoma

2. Acquired

Rheumatic diseaseCor-pulmonale
EndocarditisInferior MI
CarcinoidLeft-sided lesion

3. Normal Anatomy

A. Septal, posterior and anterior leflets
B. Annulus- sphincter-like function
C. Septal annulus- fixed
D. Dilatation only in anterior and posterior annulus

4. Functional Incompetence of the Tricuspid Valve

A. Most common form of tricuspid dysfunction
B. No leaflet or subvalvular abnormality
C. RV dilatation (secondary to left-sided lesion)
D. RV volume overload
E. Pulmonary hypertension- "Pop-Off" safety feature

5. Rheumatic disease

A. Functional TR due to left-sided lesion
B. Structural- never isolated
1) Stenosis- rare
2) Mixed- stenosis/regurgitation
C. Most common cause for tricuspid replacement

6. Endocarditis

A. Usually IV drug abusers
B. Pseudomonas/ Staph. Aureus
C. Gram negatives, fungal
D. TR, septic pulmonary emboli
E. Antibiotics highly successful

7. Clinical-- Tricuspid stenosis

A. Prominent jugular "a-wave" or atrial fibrillation
B. +/- systolic murmur
C. Enlarged liver
D. Right atrial enlargement
E. Cath >4mm enlargement

8. Clinical-- Tricuspid regurgitation

A. Cannon waves in jugular pulse
B. Pansystolic murmur
C. Pulsatile hepatomegaly/ascites/edema
D. Catheterization- not accurate
E. Echocardiography
1) Reversal of flow in IVC
2) Paradoxical atrial septal shift
3) Annular dilatation
F. Intraoperative- digital exam

9. Indications for Surgery

A. Tricuspid stenosis
1) Gradient > 4 mmHg
2) Commissurotomy vs replacement
B. Tricuspid regurgitation
1) Clinical decision- improvement with repair of left-sided lesion
2) Moderate to severe TR or any structural TR
3) RV volume overload
4) Right-sided heart failure
5) Repair vs replacement
C. Endocarditis
1) Severe TR
2) Persistent sepsis
3) Recurrent PE
4) Excision vs replacement vs repair

10. Repair

A. Ring annuloplasty
1) Shorten anterior-posterior annulus
2) Avoid septal annulus
B. Sewn annuloplasty
1) Kay
2) DeVega
C. Can be done after cross-clamp removal

11. Replacement

A. Bioprosthetic valve if >/= 28 mm
B. Smaller annulus consider prosthetic valve
C. Septal sutures in base of leaflet
D. Epicardial permanent pacemaker electrodes

12. Excision

A. If IV drug abuser ceases abuse
B. Second-stage replacement

13. Results

A. Annuloplasty
1) Addition adds minimal risk to MVR
2) Freedom from moderate/severe TR about 85% for 6 years
3) Results poorer with pulmonary hypertension
4) Reoperation for TR recurrence- rare
B. Replacement
1) Early mortality 7%
2) Porcine valve longer life than mitral position
3) Thrombosis: bileaflet < disc < ball/cage
4) Mortality- multi-vavle-disease, EF, co-morbidities
C. Excision
1) Early mortality 12%
2) Survival 63% at 15 years
3) 50% right sided heart failure
4) RV overload, septal shift, arrhythmias

14. Complications

A. Annuloplasty failure- related to pulmonary hypertension
B. Bioprosthetic calcification in younger age
C. Complete heart block
1) 10% with MVR and TR early postoperatively
2) 25% at 10 years
3) Rare after repair

15. Risk of premature death

A. Excision
B. Prior valve surgery
C. Older age at operation
D. Preoperative functional class