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← Section II · Valvular Heart Disease
II.F

Tricuspid Valve

12 cards

Notes

Anatomy

  • Three leaflets: anterior (largest), septal (smallest), posterior.
  • Best imaging views: apical 4-chamber (septal + anterior leaflets), RV inflow (anterior + posterior), PSAX at AV level (septal + anterior).
  • Tricuspid annulus dilation: > 40 mm (or 21 mm/m²) at end-diastole → likely severe primary or functional TR.

Physiologic TR

  • Nearly universal on echo (present in > 70 % of normal adults). Only mild trivial flow.

Etiology of TR

Primary (leaflet abnormality):

  • Rheumatic (usually with concomitant mitral disease).
  • Endocarditis (IVDU; septal leaflet close to a VSD).
  • Ebstein's anomaly.
  • Carcinoid (metastatic disease to liver): thickened, retracted, immobile leaflets → both stenosis and regurgitation.
  • Radiation.
  • Traumatic (leaflet flail after chest trauma).
  • Prolapse (part of myxomatous disease).
  • Pacemaker/ICD lead impingement.

Secondary (functional):

  • Annular dilation from RV or RA enlargement (pulmonary hypertension, AF, ischemic MR with LV dilation).

TR quantification - severe criteria (ASE 2017)

  • Vena contracta width ≥ 0.7 cm.
  • EROA (PISA) ≥ 0.40 cm².
  • Regurgitant volume ≥ 45 mL/beat.
  • Systolic hepatic vein flow reversal.
  • Dense CW envelope with early peaking, triangular appearance ('V wave cut-off').
  • Enlarged RA, RV, IVC (chronic).

Massive TR / torrential TR

  • Extended grading: VC > 1.4 cm (massive), > 2.1 cm (torrential).
  • Increasingly recognized in advanced heart failure and long-standing AF.

Pulmonary artery pressure from TR jet

  • PASP = 4·(TR V_peak)² + RA pressure.
  • RA pressure estimated from IVC:
    • Normal RA pressure (~3 mmHg): IVC ≤ 2.1 cm and collapses > 50 % with sniff.
    • Elevated (~15 mmHg): IVC > 2.1 cm and collapses < 50 %.
    • Intermediate (~8 mmHg): one criterion but not the other.

Mean PAP from PR

  • Mean PAP ≈ 4·(early diastolic PR velocity)².
  • PA end-diastolic pressure ≈ 4·(end-diastolic PR velocity)² + RAP.

Carcinoid heart disease

  • Metastatic mid-gut carcinoid → serotonin bypass through PFO or right-sided involvement.
  • Right heart lesions (TV + PV): thickened, retracted, immobile leaflets → mixed TR/TS and PR/PS.
  • Left heart involvement only if there is a right-to-left shunt (PFO) or a primary bronchial carcinoid.

Surgical thresholds

  • Symptomatic severe TR: valve surgery.
  • Progressive RV dilation / dysfunction with severe TR.
  • At time of left-sided valve surgery: repair TR if severe, or if tricuspid annulus > 40 mm even with mild-moderate TR.

Cards

  • basicII.F-001
    Name the three tricuspid valve leaflets and their relative sizes.
    → Anterior (largest), septal (smallest), and posterior leaflet.
  • clozeII.F-002
    Tricuspid annular dilation is present at an end-diastolic diameter > 40 mm (or 21 mm/m²).
  • basicII.F-003
    State three quantitative criteria for SEVERE tricuspid regurgitation.
    → Vena contracta ≥ 0.7 cm, EROA ≥ 0.40 cm², regurgitant volume ≥ 45 mL/beat. Also: systolic hepatic vein flow reversal, dense triangular early-peaking CW envelope.
  • basicII.F-004
    What hepatic vein finding indicates severe TR?
    → Systolic hepatic vein flow reversal. (Normal HV Doppler shows a dominant S wave forward.)
  • basicII.F-005
    How is pulmonary artery systolic pressure estimated from a TR jet?
    → PASP = 4·(TR peak velocity)² + right atrial pressure. RA pressure is estimated from IVC size and inspiratory collapsibility.
  • basicII.F-006
    Give the RA pressure estimation categories based on IVC size and collapsibility.
    → Normal RA (~3 mmHg): IVC ≤ 2.1 cm AND > 50% collapse with sniff. Elevated (~15 mmHg): IVC > 2.1 cm AND < 50% collapse. Intermediate (~8 mmHg): one criterion but not both.
  • basicII.F-007
    How do you estimate MEAN pulmonary artery pressure from a PR jet?
    → Mean PAP ≈ 4·(early diastolic PR peak velocity)².
  • basicII.F-008
    How do you estimate PA end-diastolic pressure from a PR jet?
    → PA end-diastolic pressure ≈ 4·(end-diastolic PR velocity)² + right atrial pressure.
  • basicII.F-009
    How does carcinoid heart disease typically affect the tricuspid valve?
    → Thickened, retracted, immobile leaflets → mixed tricuspid regurgitation and stenosis. The pulmonic valve is similarly affected. Left-sided involvement only occurs if there is right-to-left shunting (PFO) or bronchial carcinoid.
  • basicII.F-010
    Two most common causes of secondary (functional) tricuspid regurgitation?
    → Right ventricular / right atrial enlargement from pulmonary hypertension, and long-standing atrial fibrillation with annular dilation.
  • basicII.F-011
    When should tricuspid annuloplasty be considered at the time of left-sided valve surgery even without severe TR?
    → When the tricuspid annulus is dilated (> 40 mm) even with mild-moderate TR, since untreated annular dilation predicts future TR progression.
  • basicII.F-012
    Which leaflet of the TV is most often involved in IE from a VSD, and why?
    → Septal leaflet — its close anatomic proximity to the membranous VSD jet exposes it to bacterial deposition.