a) Tricuspid Stenosis
Acquired tricuspid stenosis is most often due to chronic rheumatic carditis.Rarely it could be due to right atrial tumors or carcinoid syndrome producingmixed stenosis and regurgitation. Right ventlicular endomyocardial fibrosis,vegetations on valve cusps or on pacing leads can give rise to a picture of tricuspid stenosis. Rheumatic bicuspid stenosis occurs in association with mitral and aortic valve affection. In postmortem, the incidence coiild be as high as 15 per cent whereas clinically it manifests only in 5 per cent of cases.
Acquired tricuspid stenosis is most often due to chronic rheumatic carditis.Rarely it could be due to right atrial tumors or carcinoid syndrome producingmixed stenosis and regurgitation. Right ventlicular endomyocardial fibrosis,vegetations on valve cusps or on pacing leads can give rise to a picture of tricuspid stenosis. Rheumatic bicuspid stenosis occurs in association with mitral and aortic valve affection. In postmortem, the incidence coiild be as high as 15 per cent whereas clinically it manifests only in 5 per cent of cases.
Indications for Surgery
Echocardiography or right heart catheterization can quantify tricuspid stenosis. It is categorized as
Echocardiography or right heart catheterization can quantify tricuspid stenosis. It is categorized as
Tricuspid valve repair is advised when there is more than moderate stenosis.When surgery is primarily done for mitral, valve disease, correction is done when there is tricuspid gradient of more than 3mms and valve orifice <2cm2.
Types of Surgery
Tricuspid valvotomy is done as an open procedure at the end of surgery on rnitral and/or aortic valve. It can be done on an arrested heart or on a beating heart on cardio pulmonary bypass with the vena cavae snared. The commissures between septal and anterior and septal and posterior are divided one mm short of the annulus. The commissures between the anterior and posterior leaflets are never divided, as it will produce significant tricuspid regurgitation. Many surgeons add a De Vega annuloplasty along with tricuspid valvotomy. If the valve cannot be repaired, tricuspid valve is replaced with a suitable bioprosthetic valve. A metallic prosthesis in tricuspid position is prohibitively thrombogenic and is not advisable.A biopl.osthesis in the tricuspid position lasts longer than in the mitral.
b)Tricuspid Regurgitation
Types of Regurgitation
Tlicuspid regurgitation can be functional or organic.
Fzlnctional Regurgitation
Dilatation of right ventricle and tricuspid annulus leads to regurgitation. This is the most common type associated with mitral valve disease and pulmonary hypertension. Anatomically, the valve is normal. The dilatation occurs at the annulus where the posterior and anterior leaflets are attached and very little at the septal leaflet attachment.
Organic lkicuspid Regurgitation
Here the valve is anatomically abnormal. Etiology of Organic tricuspid regurgitation:
1)Rheumatic
2)Non rheumatic
Tricuspid valvotomy is done as an open procedure at the end of surgery on rnitral and/or aortic valve. It can be done on an arrested heart or on a beating heart on cardio pulmonary bypass with the vena cavae snared. The commissures between septal and anterior and septal and posterior are divided one mm short of the annulus. The commissures between the anterior and posterior leaflets are never divided, as it will produce significant tricuspid regurgitation. Many surgeons add a De Vega annuloplasty along with tricuspid valvotomy. If the valve cannot be repaired, tricuspid valve is replaced with a suitable bioprosthetic valve. A metallic prosthesis in tricuspid position is prohibitively thrombogenic and is not advisable.A biopl.osthesis in the tricuspid position lasts longer than in the mitral.
b)Tricuspid Regurgitation
Types of Regurgitation
Tlicuspid regurgitation can be functional or organic.
Fzlnctional Regurgitation
Dilatation of right ventricle and tricuspid annulus leads to regurgitation. This is the most common type associated with mitral valve disease and pulmonary hypertension. Anatomically, the valve is normal. The dilatation occurs at the annulus where the posterior and anterior leaflets are attached and very little at the septal leaflet attachment.
Organic lkicuspid Regurgitation
Here the valve is anatomically abnormal. Etiology of Organic tricuspid regurgitation:
1)Rheumatic
2)Non rheumatic
- Infective endocarditis
- Ebstein's anomaly
- Floppy valve (prolapse)
- Carcinoid syndrome
- Trauma and radiation injury
- Connective tissue disorder (Marfan)
- Rheumatoid arthritis
- Endomyocardial fibrosis.
Quantification of Tricuspid Regurgitation
Echocardiography and right ventricular angiogram can quantify tricuspid regurgitation.
Echo Quantification
Trivial: Non sustained jet within l c m of the annular line with maximal jet area <5 per cent of the atrial area.
Mild: Sustained colour flaw jet with jet area 5-20 per cent of right atrium.
Moderate: Jet area 20-40 per cent.
Severe: Maximal jet area >40 per cent of right atrium, regurgitation to IVC and hepatic veins and flow reversal, in the pulmonary artery.
Angiographic Quantification
Gr 1 - minimal systolic jet, clears rapidly
Gr 2 - partial RA opacification
Gr 3 - Opacification of whole of RA
GR4 - Opacification of RA, vena cavae and hepatic veins.
Indications for Surgery
Patients with moderate or severe tricuspid regurgitation that is functional will need tricuspid $nuloplasty at the time of correction of mitral valve disease.Such patients will have pulmonary arterial and right ventricular pressure above 55mm of Hg. At the time of mitral valve surgery, mild tricuspid regurgitation may be left alone as in these patients regression of pulmonary arterial hypertension after correction of rnitral valve pathology will make tricuspid valve more competent. Moderate and severe regurgitation will have to be repaired at the time of rnitral valve surgery, for better immediate and long-term results.
In organic tricuspid regurgitation, the pulmonary artery pressure is usually less than 40mm of Hg. If the tricuspid regurgitation is severe, surgery is required in the form of valve replacement, It is better to put a bio prosthetic valve in the\tricuspid position.
Endocarditis in drug addicts may be the cause of tricuspid reguigitation. They tolerate complete excision (valvectomy) without replacement, if other cardiac valves are normal and there is no pulmonary hypertension. After about six months, when there is no danger of infection, tricuspid replacement wit11 a bio prosthetic valve could be done.
Types of Surgery
Tricuspid Annploplasty
Tricuspid valve is evaluated by digital palpation before connecting the patient to cardio pulmonary by pass. Functional regurgitation can be repaired by annuloplasty with or without a ring.
Annuloplasty with a Ring
The lings commonly used are Carpentier- Edwards and Cosgrove's flexible half ring. The rings are C shaped and have incomplete circles to accommodate the conduction patl~way. The size of [he ring is selected by the measurement of annular attachment of septal leaflet, as this portion does not get dilated usually.The properly selected ring is fixed to the annulus using 3'0' polyester sutures, leaving'the area where the bundle is lo cross the tricuspid annulus.
Echocardiography and right ventricular angiogram can quantify tricuspid regurgitation.
Echo Quantification
Trivial: Non sustained jet within l c m of the annular line with maximal jet area <5 per cent of the atrial area.
Mild: Sustained colour flaw jet with jet area 5-20 per cent of right atrium.
Moderate: Jet area 20-40 per cent.
Severe: Maximal jet area >40 per cent of right atrium, regurgitation to IVC and hepatic veins and flow reversal, in the pulmonary artery.
Angiographic Quantification
Gr 1 - minimal systolic jet, clears rapidly
Gr 2 - partial RA opacification
Gr 3 - Opacification of whole of RA
GR4 - Opacification of RA, vena cavae and hepatic veins.
Indications for Surgery
Patients with moderate or severe tricuspid regurgitation that is functional will need tricuspid $nuloplasty at the time of correction of mitral valve disease.Such patients will have pulmonary arterial and right ventricular pressure above 55mm of Hg. At the time of mitral valve surgery, mild tricuspid regurgitation may be left alone as in these patients regression of pulmonary arterial hypertension after correction of rnitral valve pathology will make tricuspid valve more competent. Moderate and severe regurgitation will have to be repaired at the time of rnitral valve surgery, for better immediate and long-term results.
In organic tricuspid regurgitation, the pulmonary artery pressure is usually less than 40mm of Hg. If the tricuspid regurgitation is severe, surgery is required in the form of valve replacement, It is better to put a bio prosthetic valve in the\tricuspid position.
Endocarditis in drug addicts may be the cause of tricuspid reguigitation. They tolerate complete excision (valvectomy) without replacement, if other cardiac valves are normal and there is no pulmonary hypertension. After about six months, when there is no danger of infection, tricuspid replacement wit11 a bio prosthetic valve could be done.
Types of Surgery
Tricuspid Annploplasty
Tricuspid valve is evaluated by digital palpation before connecting the patient to cardio pulmonary by pass. Functional regurgitation can be repaired by annuloplasty with or without a ring.
Annuloplasty with a Ring
The lings commonly used are Carpentier- Edwards and Cosgrove's flexible half ring. The rings are C shaped and have incomplete circles to accommodate the conduction patl~way. The size of [he ring is selected by the measurement of annular attachment of septal leaflet, as this portion does not get dilated usually.The properly selected ring is fixed to the annulus using 3'0' polyester sutures, leaving'the area where the bundle is lo cross the tricuspid annulus.
Tricuspid Excision
For tricuspid valve endocarditis with vegetations in dlug users, valve excision is done by removing three cusps and chordae and papillary muscles. Later on, they will need tricuspid valve replacement with bio prosthesis.
Wcuspid Valve Replacement
It is done for organic tricuspid valve disease and at times for functional tricuspid regurgitation. When done along with other procedures, it is done last when patient is being rewanned. The advantage is that one can do it after removing aortic cross clamp and on a beating heart, thereby reducing cardiac ischaemic time. Valve is excised leaving 2-3 mms of cuspal tissue. Inteilupted, pledgetted mattress sutures are taken with special care at the region of the penetrating bundle of his. Continuous prolene sutures can also be used for valve replacement.
Results: Early mortality for tricuspid valve replacement is around six per cent.But depending on the patient's class of symptoms and the number of concomitant procedures, this can be as high as 27 per cent. Survival at 10 years is around 55 per cent and death is often the result of other valve involvement.The incidence of complete heart block is around six per cent. In a series with combined rnitral and tricuspid valve replacement, 10 per cent required permanent pace maker insertion,
c)Mixed Tricuspid Stenosis and Regurgitation
Rheumatic involvement of the tricuspid valve is often seen in association with involvement of mitral and rarely aortic valve. Isolated rheumatic tricuspid valve disease is not seen. It usually produces tricuspid regurgitation with some amount of stenosis due to fibrosis and fusion of cornrnissures. Chordal thickening and fusion are usually mild and calcification is rarely seen. The other cause for combined stenosis and regurgitation is carcinoid syndrome. It mainly affects pulmonary and tricuspid valves (right sided cardiac valves). They will need tricuspid valve replacement with bio prosthesis. Valve cusps are thickened along with thickening and fusion of chordae. This produces a picture of mixed stenosis and regurgitation.
Indications for Surgery
In a mixed lesion, either regurgitation or stenosis may be dominant and decision of surgery depends on the haemodynarnics. At the time of surgery on other cardiac valves, tricuspid valve will have to be assessed and decision taken.Carcinoid affection of the tricuspid valve will need valve replacement but prognosis depends on the original condition and age of patient.
Types of Surgery
Combined' lesion of the tricuspid valve is best managed with bioprosthetic valve replacement. Open valvotomy with valvuloplasty is most often unsuccessful.
For tricuspid valve endocarditis with vegetations in dlug users, valve excision is done by removing three cusps and chordae and papillary muscles. Later on, they will need tricuspid valve replacement with bio prosthesis.
Wcuspid Valve Replacement
It is done for organic tricuspid valve disease and at times for functional tricuspid regurgitation. When done along with other procedures, it is done last when patient is being rewanned. The advantage is that one can do it after removing aortic cross clamp and on a beating heart, thereby reducing cardiac ischaemic time. Valve is excised leaving 2-3 mms of cuspal tissue. Inteilupted, pledgetted mattress sutures are taken with special care at the region of the penetrating bundle of his. Continuous prolene sutures can also be used for valve replacement.
Results: Early mortality for tricuspid valve replacement is around six per cent.But depending on the patient's class of symptoms and the number of concomitant procedures, this can be as high as 27 per cent. Survival at 10 years is around 55 per cent and death is often the result of other valve involvement.The incidence of complete heart block is around six per cent. In a series with combined rnitral and tricuspid valve replacement, 10 per cent required permanent pace maker insertion,
c)Mixed Tricuspid Stenosis and Regurgitation
Rheumatic involvement of the tricuspid valve is often seen in association with involvement of mitral and rarely aortic valve. Isolated rheumatic tricuspid valve disease is not seen. It usually produces tricuspid regurgitation with some amount of stenosis due to fibrosis and fusion of cornrnissures. Chordal thickening and fusion are usually mild and calcification is rarely seen. The other cause for combined stenosis and regurgitation is carcinoid syndrome. It mainly affects pulmonary and tricuspid valves (right sided cardiac valves). They will need tricuspid valve replacement with bio prosthesis. Valve cusps are thickened along with thickening and fusion of chordae. This produces a picture of mixed stenosis and regurgitation.
Indications for Surgery
In a mixed lesion, either regurgitation or stenosis may be dominant and decision of surgery depends on the haemodynarnics. At the time of surgery on other cardiac valves, tricuspid valve will have to be assessed and decision taken.Carcinoid affection of the tricuspid valve will need valve replacement but prognosis depends on the original condition and age of patient.
Types of Surgery
Combined' lesion of the tricuspid valve is best managed with bioprosthetic valve replacement. Open valvotomy with valvuloplasty is most often unsuccessful.
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