Ryan Nowrouzi MD, Martin Kosztowski MD, Marc R. Moon MD
Baylor College of Medicine
August 31, 2024
Abbreviations & Definitions
COR – Class of recommendation
LOE – Level of evidence
TR – Tricuspid regurgitation
TS – Tricuspid stenosis
TTE – Transthoracic echocardiography
Indications & Guidelines for Management by Grade/Stage of Disease
Isolated tricuspid stenosis (TS) is a rare valvular pathology. More frequently, this disease process is seen along with other concomitant processes such as mitral valve disease or in addition to tricuspid regurgitation (TR). The most common etiology of TS is rheumatic heart disease. Other less common etiologies include autoimmune disorders, including systemic lupus erythematosus or antiphospholipid antibody syndrome, as well as carcinoid syndrome. The pathophysiology of this disease arises from narrowing of the tricuspid valve, which in turn leads to an increased pressure gradient between the right atrium and right ventricle. Downstream consequences of this include decreased right ventricular output and systemic congestion.1
Classification of TS severity has historically remained far less granular than all other valve pathologies. A classification schema adapted from the American Heart Institute executive summary, as well as a summary review by Golamari et al, lay out stages of TS.1,2 TS is classified into four distinct stages based on disease severity and symptoms, each with its own management strategy. Stage A refers to patients at risk of developing TS, but who show no signs of the condition. In this stage, no intervention is indicated. Stage B includes individuals with mild to moderate disease who are asymptomatic. Like Stage A, no intervention is required at this point. Stage C is characterized by severe TS in asymptomatic patients. For these patients, a Class I recommendation for intervention arises if they are undergoing a concomitant left-sided valve procedure, recognizing that TS may become more problematic during such interventions. Finally, Stage D describes severe, symptomatic TS, where intervention is necessary with a Class I recommendation for surgical or percutaneous treatment.
Imaging, particularly transthoracic echocardiography (TTE), remains the primary diagnostic tool in evaluating TS, as it is for many other valvular heart diseases. Specifically, in 2009, a set of criteria jointly laid out by the European Association of Echocardiography (EAE) and the American Society of Echocardiography (ASE) indicates echocardiographic measurements that are routinely used as objective indicators of hemodynamically significant TS.3
Hemodynamically significant TS is identified through a combination of quantitative and supportive echocardiographic findings. Key diagnostic measurements include a mean pressure gradient across the tricuspid valve of ³5 mmHg, an inflow time-velocity integral >60 cm, and a pressure half-time (T1/2) of ³190 milliseconds. Additionally, a tricuspid valve area of £1 cm², as calculated by the continuity equation, supports the diagnosis. Complementary structural findings that further substantiate the presence of significant stenosis include at least moderate enlargement of the right atrium and a dilated inferior vena cava, both of which reflect elevated right atrial pressures and chronic impedance of flow through the tricuspid valve.
The decision to intervene upon TS relies upon the degree of symptomology as well as the existence of concurrent pathology. In 2014, guidelines for intervention were published in the AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Class I recommendations include 1) tricuspid valve surgery for patients with severe TS who are undergoing left-sided valve operation and 2) tricuspid valve surgery for patients with isolated, severe, symptomatic TS. A Class IIb recommendation exists for patients with isolated, symptomatic, severe TS without accompanying TR, which states percutaneous balloon tricuspid commissurotomy may be considered (Table 1).3,4
Table 1. Intervention Guideline for TS.
| Recommendations | COR | LOE | Source |
|---|---|---|---|
| Tricuspid valve surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease. | I | C | 5 |
| Tricuspid valve surgery is recommended for patients with isolated, symptomatic, severe TS. | I | C | 6 |
| Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated, symptomatic, severe TS without accompanying TR. | IIb | C | 7 |
Supporting Evidence for Current Indications & Guidelines
The 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary provides an overview of staging and management of TS. TS is classified into four stages (A–D) based on severity and symptoms, with intervention typically reserved for severe or symptomatic cases, or when left-sided valve surgery is planned. Current AHA/ACC guidelines recommend surgery for patients with severe TS undergoing left-sided procedures or with isolated symptomatic disease, while percutaneous options may be considered in select cases.2,3
Ongoing Trials/Recent Publications
Most data surrounding TS are based on the 2014 AHA/ACC guidelines, as well as retrospective data cited in this review chapter. No ongoing major trials or publications are known.
Sources
- Golamari R, Shams P, Alahmadi MH, et al. Tricuspid Stenosis. [Updated 2024 Jun 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499990/#
- Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD; ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10;129(23):2440-92. doi: 10.1161/CIR.0000000000000029. Epub 2014 Mar 3. Erratum in: Circulation. 2014 Jun 10;129(23):e650. PMID: 24589852.
- Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M; American Society of Echocardiography; European Association of Echocardiography. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009 Jan;22(1):1-23; quiz 101-2. doi: 10.1016/j.echo.2008.11.029. Erratum in: J Am Soc Echocardiogr. 2009 May;22(5):442. Erratum in: J Am Soc Echocardiogr. 2023 Apr;36(4):445. doi: 10.1016/j.echo.2023.02.005. PMID: 19130998.
- Fiedler AG, Sullivan J, Walker JD. Tricuspid Valve. In: Baumgartner WA, Jacobs JP, Meyerson S, eds. Adult and Pediatric Cardiac Surgery. STS Cardiothoracic Surgery E-Book. Chicago: Society of Thoracic Surgeons; 2023. ebook.sts.org. Accessed August 22, 2024.
- Lee R, Li S, Rankin JS, et al. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg. 2011;91:677–84.
- Orbe LC, Sobrino N, Arcas R, et al. Initial outcome of percutaneous balloon valvuloplasty in rheumatic tricuspid valve stenosis. Am J Cardiol. 1993;71:353–4.
- Yeter E, Ozlem K, Kilic H, et al. Tricuspid balloon valvuloplasty to treat tricuspid stenosis. J Heart Valve Dis. 2010;19:159–60.
