Right sided valve disease

Tricuspid regurgitation

• Signs
  • • Raised JVP
    • Pansystolic murmur over left sternal edge and loudest in inspiration
    • Pulsatile hepatomegaly
    • Peripheral oedema
• If mild or moderate, usually no haemodynamic consequences
• Severe TR can cause right sided heart failure, and is often associated with functional MR
• Causes
  • • Usually functional ie secondary to dilated RV and/or RA, which itself can be caused by pulmonary hypertension / respiratory disease, dilated cardiomyopathy, RV MI, mitral valve disease.
    • Primary TR (9%) – anatomical abnormality of the valve, can be due to IE (in IVDUs), carcinoid, rheumatic heart disease, Ebstein’s anomaly, previous radiotherapy, myxomatous disease, trauma/iatrogenic
    • Can be related to implantable devices (lead-induced). Managed differently
• Investigations
  • • ECG may suggest RVH
    • Echo – can suggest a cause, impact of the TR, and severity (assess when euvolaemic)
    • Severe TR is suggested by effective regurgitant orifice area >40mm², RVol >45mL/beat, RF >50%
    • In the setting of severe TR, RV function is often overestimated, and pulmonary pressures and often underestimated
    • CMR better at assessing RV size and function (if this is key to decision making)
    • Right heart catheter and gated CTCA often done prior to valve interventions
• Severe TR has a poor prognosis / debilitating symptoms
  • • Patients are often on massive doses of diuretics (or have recurrent admissions for offloading) and lots of oedema
    • AF, SOB and fatigue are very common
• Management
  • • Depends a bit on aetiology, but diuretics and ACE-I commonly used
    • HF and AF treated in usual way
    • Medical treatment has little impact on evolution/severity of TR
    • If device-related – may need lead extraction
• Surgery
  • • Patients often referred late (hence why TV surgery is often high risk)
    • Generally considered if:
      • • Primary severe TR with symptoms
        • Symptomatic severe secondary TR
        • Asymptomatic severe TR with RV dilatation or deterioration
        • Moderate or severe TR and the patient also requires left sided valve surgery
    • No role for surgery if severe LV or RV dysfunction or pulmonary hypertension (risks too high)
    • Transcatheter repair for TR (Tricuspid TEER)
      • • Can repair the tricuspid valve if TR moderate/severe and patient is having MV or AV surgery
        • Only done in a few centres
        • Improves quality of life, unclear about effect on mortality (none noted yet)
        • Not recommended if life expectancy is very limited – can use a scoring system
        • Refer if severe TR with lots of symptoms on maximal medical therapy (though not he capacity currently to help everyone)
        • Lots of diuresis before the procedure is important
        • TOE for planning
        • Single anti-platelet afterwards if not anticoagulated
        • 2% risk of single leaflet detachment – sudden worsening of TR down the line. May need another corrective procedure
    • Valve replacement is usually reserved for advanced disease with annular dilation and leaflet tethering, or if repair fails
• Follow up
  • • If TR severe or moderate – echo and clinical review every 6 months

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Tricuspid Stenosis

• Rare
• Causes
  • • Rheumatic heart disease (often with combined TR)
    • Whipple’s disease
    • Fabry’s disease
    • Carcinoid
    • Mediations (fenfluramine or methysergide)
    • IE
    • Device-associated thrombus
• Clinical features – presystolic murmur and mid diastolic murmur
• Echo – A mean diastolic transvalvular gradient of >5 mmHg at a normal heart rate indicates severe TS
• Management
  • • Medical therapy as bridge to surgery, often with diuretics
    • Surgery is advised in severe TS
    • Consider repair if young, but valve replacement is often done
    • Tissue valves best (metal valves have a high risk of clotting off in the low-pressure system)

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Pulmonary valve lesions

• Both PS and PR can have an ejection systolic murmur
• Pulmonary stenosis
  • • Usually congenital, can be part of Fallots
    • Occasionally due to rheumatic fever or carcinoid
    • Associated with Noonan’s syndrome
• Pulmonary regurgitation
  • • Usually due to pulmonary hypertension
    • Can also have Graham Steel murmur (decrescendo early diastolic)