Tricuspid stenosis is mainly due to ARF, most commonly associated with left-sided valvular lesions. It may also be congenital or occur in carcinoid syndrome (associated with pulmonary valve damage) and endomyofibrosis (associated with systolic-diastolic dysfunction).
Video: Tricuspid disease on carcinoid syndrome; the valve does not open normally in diastole (stenosis) and does not occlude in systole (insufficiency).
The valve shows commissural fusions and a restrictive appearance with limited motion; it domes in diastole (doming); the subvalvular apparatus is shortened and thickened (Figure 11.160C). The RA is dilated (diameter > 5 cm), as are the inferior vena cava (> 2 cm) and the suprahepatic veins. While the normal tricuspid surface area is 5-7 cm2, stenosis corresponds to a surface area of < 2 cm2. The mean gradient, normally less than 2 mmHg, then becomes greater than 5 mmHg; these are the values at which symptoms of systemic congestion occur [2].
There are three degrees of tricuspid stenosis:
- Mild stenosis ΔPmean 2-3 mmHg S 1.5 - 2.0 cm2
- Moderate stenosis ΔPmean 4-6 mmHg S 1.0 - 1.5 cm2
- Severe stenosis ΔPmean > 7 mmHg S ≤ 1 cm2
Haemodynamically, the condition results in an elevated CVP with a predominant "a" wave. Pulmonary pressure is normal, except in cases of associated mitral valve disease, but pulmonary flow is restricted and cannot increase with exercise. If the body's VO2 is increased (stress, pain), hypoxaemia occurs very rapidly.
Medical treatment is aimed at systemic congestion (oedema, ascites, hepatomegaly): fluid and sodium restriction, diuretics. Surgical treatment consists of open valvulotomy by splitting the commissures on either side of the septal leaflet, valvuloplasty in the presence of associated insufficiency or, very rarely, valve replacement [1]. Bioprostheses are generally preferred to mechanical valves, which carry a high risk of thrombosis, and are less likely to degrade in a low-pressure, slow-flow system [2].
Anaesthesia principles for tricuspid stenosis
Preload (CVP) must remain high to maintain minimal flow through the stenosis. The heart rate must remain slow to allow a long diastole; the onset of any tachyarrhythmia (AF) will collapse the flow through the stenosis and must be corrected immediately (cardioversion, amiodarone). In the absence of any associated left-sided pathology, RV function and pulmonary pressures are normal, but pulmonary flow is low and the risk of hypoxaemia is high. In the case of arterial hypotension, the choice is an alpha vasoconstrictor (phenylephrine, noradrenaline) to increase the SAR.
Passage of a Swan-Ganz catheter is virtually impossible and in any case a hindrance to the operator. Monitoring consists of an arterial catheter, a central venous line (CVP), an arterial waveform analyser (PiCCO type) and TEE. A left atrial catheter placed intraoperatively can guide LV monitoring, but there is a risk of bleeding if it is removed postoperatively.
| Hemodynamic sought in tricuspid stenosis |
| High stable right preload
Systemic vasoconstriction Full - Slow - Closed |
© CHASSOT PG, BETTEX D, August 2011, last update November 2019
References
- DEL CAMPO C, SHERMAN JR. Tricuspid valve replacement: Results conmparing mechanical and biological prostheses. Ann Thorac Surg 2000; 69:1295-303
- VAHANIAN A, ALFIERI O, ANDREOTTI F, et al. Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2012; 33:2451-96