Tricuspid Valve Pathology

  • Shahzad G. Raja


Tricuspid valve pathology has increasingly become the focus of attention in recent years. Both primary and secondary disease processes involve the tricuspid valve. Depending on the underlying disease process the predominant hemodynamic lesion can be either tricuspid valve stenosis or regurgitation. Whereas tricuspid stenosis is uncommon, tricuspid regurgitation is frequently encountered and is most often secondary in nature. Patients with tricuspid valve disease are usually in an advanced stage of multivalvular heart disease and constitute a high-risk group. Recent improved understanding of the pathophysiology of tricuspid valve disease coupled with substantial advances in assessment and management have improved the outlook for patients with tricuspid valve pathology. This chapter provides an overview of tricuspid valve pathology focusing on pathophysiology, diagnosis, management and emerging transcatheter therapies.


Atrioventricular valve Tricuspid valve Tricuspid stenosis Tricuspid regurgitation Functional regurgitation 


  1. 1.
    Shah PM, Raney AA. Tricuspid valve disease. Curr Probl Cardiol. 2008;33:47–84.CrossRefPubMedGoogle Scholar
  2. 2.
    Bruce CJ, Connolly HM. Right-sided valve disease deserves a little more respect. Circulation. 2009;119:2726–34.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Guenther T, Norbauer C, Mazzitelli D, Busch RB, Tassani-Prell P, Lange R. Tricuspid valve surgery: a thirty-year assessment of early and late outcome. J Cardiothorac Surg. 2008;34:402–9.CrossRefGoogle Scholar
  4. 4.
    Singh SK, Tang GHL, Maganti MD, Armstrong S, Williams WG, David TE, et al. Midterm outcomes of tricuspid valve repair versus replacement for organic tricuspid disease. Ann Thorac Surg. 2006;82:1735–41.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    McCarthy PM, Bhudia SK, Rajeswaran J, Hoercher KJ, Lytle BW, Cosgrove DM, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg. 2004;127:674–85.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Shah PM. Tricuspid and pulmonary valve disease evaluation and management. Rev Esp Cardiol. 2010;63:1349–65.CrossRefPubMedGoogle Scholar
  7. 7.
    Tei C, Pilgrim JP, Shah PM, Ormiston JA, Wong M. The tricuspid valve annulus: study of size and motion in normal subjects and in patients with tricuspid regurgitation. Circulation. 1982;6:665–71.CrossRefGoogle Scholar
  8. 8.
    Joudinaud TM, Flecher EM, Duran CM. Functional terminology for the tricuspid valve. J Heart Valve Dis. 2006;15:382–8.PubMedGoogle Scholar
  9. 9.
    Waller BF, Moriarty AT, Eble JN, Davey DM, Hawley DA, Pless JE. Etiology of pure tricuspid regurgitation based on annular circumference and leaflet area: analysis of 45 necropsy patients with clinical and morphologic evidence of pure tricuspid regurgitation. J Am Coll Cardiol. 1986;7:1063–74.CrossRefPubMedGoogle Scholar
  10. 10.
    Waller BF, Howard J, Fess S. Pathology of tricuspid valve stenosis and pure tricuspid regurgitation part III. Clin Cardiol. 1995;18:225–30.CrossRefPubMedGoogle Scholar
  11. 11.
    Shiran A, Sagie A. Tricuspid regurgitation in mitral valve disease. J Am Coll Cardiol. 2009;53:401–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Adler DS. Non-functional tricuspid valve disease. Ann Cardiothorac Surg. 2017;6:204–13.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Wooley CF, Fontana ME, Kilman JW, Ryan JM. Tricuspid stenosis: atrial systolic murmur, tricuspid opening snap, and right atrial pressure pulse. Am J Med. 1985;78:375–84.CrossRefPubMedGoogle Scholar
  14. 14.
    Tei C, Shah PM, Tanaka H. Phonographic-echographic documentation of systolic honk in tricuspid prolapse. Am Heart J. 1982;103:294–5.CrossRefPubMedGoogle Scholar
  15. 15.
    Rivera JM, Vandervoort PM, Vazquez de Prada JA, Mele D, Karson TH, Morehead A. Which physical factors determine tricuspid regurgitation jet area in the clinical setting? Am J Cardiol. 1993;72:1305–9.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. A report from the American Society of Echocardiography’s nomenclature and standards committee and the task force on valvular regurgitation. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Tei C, Shah PM, Cherian G, Trim PA, Wong M, Ormiston JA. Echocardiographic evaluation of normal and prolapsed tricuspid valve leaflets. Am J Cardiol. 1983;52:796–800.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Fuster V, O’Rourke RA, Poole-Wilson P. Tricuspid valve, pulmonary valve and multiple valve disease. Hurst’s The Heart. 2009;13:1745–56.Google Scholar
  19. 19.
    Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid regurgitation or dilatation: which should be criteria for surgical repair? Ann Thorac Surg. 2005;79:127–32.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, 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;129:2440–92.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Bernal JM, Pontón A, Diaz B, Llorca J, García I, Sarralde A, Diago C, Revuelta JM. Surgery for rheumatic tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg. 2008;136:476–81.CrossRefPubMedGoogle Scholar
  22. 22.
    Raja SG, Dreyfus GD. Surgery for functional tricuspid regurgitation: current techniques, outcomes and emerging concepts. Expert Rev Cardiovasc Ther. 2009;7:73–84.CrossRefPubMedGoogle Scholar
  23. 23.
    De Vega NG. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol. 1972;25:555–6. [Spanish].PubMedGoogle Scholar
  24. 24.
    Hata H, Fujita T, Shimahara Y, Sato S, Kobayashi J. Early and mid-term outcomes of aggressive tricuspid annuloplasty with the MC3 ring. J Heart Valve Dis. 2014;23:601–8.PubMedGoogle Scholar
  25. 25.
    Alfieri O, De Bonis M, Lapenna E, Agricola E, Quarti A, Maisano F. The “clover technique” as a novel approach for correction of post-traumatic tricuspid regurgitation. J Thorac Cardiovasc Surg. 2003;126:75–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Lai YQ, Meng X, Bai T, Zhang C, Luo Y, Zhang ZG. Edge-to-edge tricuspid valve repair: an adjuvant technique for residual tricuspid regurgitation. Ann Thorac Surg. 2006;81:2179–82.CrossRefPubMedGoogle Scholar
  27. 27.
    Kay JH, Maselli-Campagna G, Tsuji KK. Surgical treatment of tricuspid insufficiency. Ann Surg. 1965;162:53–8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Dreyfus GD, Raja SG, John Chan KM. Tricuspid leaflet augmentation to address severe tethering in functional tricuspid regurgitation. Eur J Cardiothorac Surg. 2008;34:908–10.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Tanaka M, Ohata T, Fukuda S, Kigawa I, Yamashita Y, Wanibuchi Y. Tricuspid valve supra-annular implantation in adult patients with Ebstein’s anomaly. Ann Thorac Surg. 2001;71:582–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Ratnatunga CP, Edwards MB, Dore CJ, Taylor KM. Tricuspid valve replacement: UK heart valve registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg. 1998;66:1940–7.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Rizzoli G, Vendramin I, Nesseris G, Bottio T, Guglielmi C, Schiavon L. Biological or mechanical prostheses in tricuspid position? A meta-analysis of intra-institutional results. Ann Thorac Surg. 2004;77:1607–14.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Al-Najashi KS, Balint OH, Oechslin E, Williams WG, Silversides CK. Mid-term outcomes in adults with Ebstein anomaly and cavopulmonary shunts. Ann Thorac Surg. 2009;88:131–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Functional status after operation for Ebstein anomaly. J Am Coll Cardiol. 2008;52(6):460–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Moller JE, Pellikka PA, Bernheim AM, Schaff HV, Rubin J, Connolly HM. Prognosis of carcinoid heart disease analysis of 200 cases over two decades. Circulation. 2005;112:3320–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Raja SG, Bhattacharyya S, Davar J, Dreyfus GD. Surgery for carcinoid heart disease: current outcomes, concerns and controversies. Futur Cardiol. 2010;6:647–55.CrossRefGoogle Scholar
  36. 36.
    Yee ES, Khonsari S. Right-sided infective endocarditis: valvuloplasty, valvectomy or replacement. J Cardiovasc Surg. 1989;30:744–8.Google Scholar
  37. 37.
    Konstantinov IE. Total resection and complete reconstruction of the tricuspid valve in acute infective endocarditis. J Thorac Cardiovasc Surg. 2008;136(2):531.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Veerbhadran SP, Pillai VV, Sasidharan B, Karunakaran J. Surgery for congenital tricuspid valve cleft: tricuspid valve repair with neochordae and annuloplasty. J Heart Valve Dis. 2015;24:525–7.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Uehara K, Minakata K, Watanabe K, Sakaguchi H, Yamazaki K, Ikeda T, et al. Tricuspid valve repair for severe tricuspid regurgitation due to pacemaker leads. Asian Cardiovasc Thorac Ann. 2016;24:541–5.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Bouleti C, Juliard JM, Himbert D, Iung B, Brochet E, Urena M, et al. Tricuspid valve and percutaneous approach: no longer the forgotten valve! Arch Cardiovasc Dis. 2016;109:55–66.CrossRefPubMedGoogle Scholar
  41. 41.
    Schofer J, Bijuklic K, Tiburtius C, Hansen L, Groothuis A, Hahn RT. First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve. J Am Coll Cardiol. 2015;65:1190–5.CrossRefPubMedGoogle Scholar
  42. 42.
    Latib A, Agricola E, Pozzoli A, Denti P, Taramasso M, Spagnolo P, et al. First-in-man implantation of a tricuspid annular remodeling device for functional tricuspid regurgitation. JACC Cardiovasc Interv. 2015;8:e211–4.CrossRefPubMedGoogle Scholar
  43. 43.
    Ruiz CE, Kliger C, Perk G, Maisano F, Cabalka AK, Landzberg M, et al. Transcatheter therapies for the treatment of valvular and paravalvular regurgitation in acquired and congenital valvular heart disease. J Am Coll Cardiol. 2015;66:169–83.CrossRefPubMedGoogle Scholar
  44. 44.
    Rogers T, Ratnayaka K, Sonmez M, Franson DN, Schenke WH, Mazal JR, Kocaturk O, Chen MY, Faranesh AZ, Lederman RJ. Transatrial intrapericardial tricuspid annuloplasty. JACC Cardiovasc Interv. 2015;8:483–91.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Shahzad G. Raja
    • 1
  1. 1.Department of Cardiac SurgeryHarefield HospitalHarefield, MiddlesexUK

Personalised recommendations