TRICUSPID AND

PULMONARY VALVE
DISORDERS
BY DR.SATHYANARAYANAN
M6 – PROF. DR. A. SAMUEL DINESH UNIT
MMC & RGGGH
TRICUSPID STENOSIS
EPIDEMIOLOGY
1) RHEUMATIC – almost always associated with rheumatic ms
2) CONGENITAL – very rarely seen
PATHOPHYSIOLOGY
• Mean diastolic gradient of 4mmHg

• Elevated RA pressures

• Venous congestion
CLINICAL FEATURES
• Swelling of legs, abdominal distension, fatigue, neck pulsations
• Giant a wave , prolonged y descent
• Hepatic pulsations
• S1 loud, Opening snap, decrescendo Mid-Diastolic Murmur, carvello’s
sign, decreased during expiration and Valsalva.

ECG: P-pulmonale in lead 2

ECHOCARDIOGRAPHY
• Doming of the tricuspid valve
• Transvalvular gradients
• Valve area (<1cm2 – severe)
• Pressure half time >190ms
• RA , RV enlargement, pulmonary hypertension
TREATMENT
• Salt restriction
• Diuretics
• Valve replacement or commisurotomy – during MVR or CMC
• Moderate or severe TS (valve gradient >4mmHg, valve area <1.5-
2cm2)
TRICUSPID REGURGITATION
PRIMARY SECONDARY

RHEUMATIC PULMONARY HYPERTENSION

ENDOCARDITIS RVMI

MYXOMATOUS (TVP) LEFT SIDED HEART DISEASES

CARCINOID CARDIOMYOPATHY

RADIATION AF

EBSTEIN’S ANAMOLY CHRONIC RV PACING

PAPILLARY MUSCLE INJURY

CLINICAL FEATURES
• Swelling of legs, abdominal distension, fatigue, neck pulsations
• Prominent cv waves, rapid y descent, ventricularization of RA wave
• Hepatic pulsations
• S1 soft, harsh blowing holosystolic murmur along left parasternal
border.

ECG: P-pulmonale in lead 2

ECHOCARDIOGRAPHY
TREATMENT
PULMONARY STENOSIS
• Congenital
• Noonan syndrome – PTPN 1 gene mutation in chromosome 12
PATHOPHYSIOLOGY
• Increased systolic pressure gradient between RV & pulmonary artery
• Afterload mismatch
• RV hypertrophy
CLINICAL FEATURES
• Right sided symptoms
• Left 2nd ICS pulsation, palpable P2, loud p2, ejection systolic click
• Crescendo-decrescendo ejection systolic murmur heard in left 2nd ICS
• Pulmonary ejection click decrease in intensity during inspiration.

ECG:
1) P-pulmonale in lead 2
2) V1 Rwave >7mm
 ECHOCARDIOGRAPHY
SEVERITY VELOCITY PEAK PRESSURE GRADIENT

MILD PS <3m/s <34mmHg

MODERATE PS 3-4m/s 36-64mmHg

SEVERE PS >4m/s >64mmHg

TREATMENT
• DIURETICS
• PERCUTANEOUS PULMONIC BALLOON VALVOPLASTY - SEVERE PS &
SYMPTOMATIC PS, C/I IN MODERATE TO SEVERE PR
PULMONARY REGURGITATION
• Percutaneous pulmonic balloon valvoplasty
• Repair of TOF, pulmonary atresia(RA-PV conduit)
• Functional PR due to annular dilatation
• Carcinoid , endocarditis
• High pitched decrescendo diastolic murmur (graham-steel murmur)
heard along left 2nd ICS.
• Treatment – treatment of pulmonary hypertension, diuretics,
pulmonary valve replacement.