What is the treatment approach for tricuspid valve stenosis?

Treatment of Tricuspid Valve Stenosis

Surgery is the recommended treatment for symptomatic patients with severe tricuspid stenosis and for patients with severe tricuspid stenosis undergoing left-sided valve intervention. 1

Diagnosis and Evaluation

• Tricuspid stenosis is a rare condition, most commonly of rheumatic origin, and is almost always associated with left-sided valve lesions that may dominate the clinical presentation 1, 2
• Careful echocardiographic evaluation is essential as tricuspid stenosis is often overlooked; TTE is indicated to assess valve anatomy, evaluate stenosis severity, and characterize any associated regurgitation 1
• Severe tricuspid stenosis is characterized by mean pressure gradient >5 mm Hg, pressure half-time ≥190 ms, and valve area ≤1.0 cm² 1
• Invasive hemodynamic assessment may be considered in symptomatic patients when clinical and noninvasive data are discordant 1

Medical Management

• Diuretics are useful for symptom relief in patients with heart failure and congestion but have limited long-term efficacy 1
• Medical therapy alone is generally insufficient for managing severe tricuspid stenosis and should be considered primarily for symptom management while awaiting definitive intervention 1

Surgical Management

• Surgery is indicated for:

  • Symptomatic patients with severe tricuspid stenosis 1
  • Patients with severe tricuspid stenosis undergoing left-sided valve intervention 1

• The choice between valve repair or replacement depends on valve anatomy and surgical expertise 1

• Biological prostheses are usually preferred over mechanical ones for tricuspid valve replacement due to the high risk of thrombosis with mechanical valves and satisfactory long-term durability of biological prostheses in the tricuspid position 1

Percutaneous Interventions

• Percutaneous balloon tricuspid dilatation has been performed in limited cases but frequently induces significant regurgitation 1
• Balloon commissurotomy can be considered only in rare cases with anatomically suitable valves when:
  • Tricuspid stenosis is isolated, or
  • Additional mitral stenosis can also be treated interventionally 1
• There is a lack of data on long-term results with percutaneous approaches 1, 3

Special Considerations

• Combined tricuspid stenosis and regurgitation requires careful evaluation; when both are present, management follows recommendations for the predominant lesion 1
• When the severity of both stenosis and regurgitation is balanced, intervention decisions should be based on symptoms and objective consequences rather than indices of severity 1
• Severe combined tricuspid stenosis and regurgitation is a contraindication to percutaneous mitral commissurotomy when mitral stenosis is also present 1

Follow-up

• Regular echocardiographic assessment is essential to evaluate disease progression, right ventricular function, and response to therapy 4
• Patients with tricuspid valve disease should be monitored for development of pulmonary hypertension 4

Common Pitfalls

• Underestimating the severity of tricuspid stenosis due to its association with more dominant left-sided valve disease 1, 2
• Delaying intervention until severe right ventricular dysfunction develops, which worsens surgical outcomes 1, 4
• Inadequate assessment of valve anatomy leading to inappropriate selection of repair versus replacement strategies 1