(See also Overview of Cardiac Valvular Disorders Overview of Cardiac Valvular Disorders Any heart valve can become stenotic or insufficient (also termed regurgitant or incompetent), causing hemodynamic changes long before symptoms occur. Depending on which valve is involved, the... read more .)
Tricuspid stenosis is almost always due to rheumatic fever Rheumatic Fever Rheumatic fever is a nonsuppurative, acute inflammatory complication of group A streptococcal pharyngeal infection, causing combinations of arthritis, carditis, subcutaneous nodules, erythema... read more 
; tricuspid regurgitation Tricuspid Regurgitation Tricuspid regurgitation (TR) is insufficiency of the tricuspid valve causing blood flow from the right ventricle to the right atrium during systole. The most common cause is dilation of the... read more is almost always also present, as is rheumatic mitral valvulopathy (usually mitral stenosis Mitral Stenosis Mitral stenosis is narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle. The usual cause is rheumatic fever. Common complications are pulmonary... read more ).
Rare causes of tricuspid stenosis include systemic lupus erythematosus Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more 
, right atrial myxoma, congenital malformations, and metastatic tumors.
The right atrium becomes hypertrophied and distended, and sequelae of right heart disease–induced heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more 
develop but without right ventricular (RV) dysfunction; the RV remains underfilled and small. Uncommonly, atrial fibrillation occurs.
Symptoms and Signs of Tricuspid Stenosis
The only symptoms of severe tricuspid stenosis are fluttering discomfort in the neck (due to giant a waves in the jugular pulse), fatigue and cold skin (due to low cardiac output), and right upper quadrant abdominal discomfort (due to an enlarged liver). Patients with mild tricuspid stenosis have no symptoms.
The primary visible sign is a giant flickering a wave with gradual y descent in the jugular veins. Jugular venous distention may occur, increasing with inspiration (Kussmaul sign). The face may become dusky and scalp veins may dilate when the patient is recumbent (suffusion sign). Hepatic congestion and peripheral edema may occur.
Auscultation
Soft opening snap
Mid-diastolic rumble with presystolic accentuation
On auscultation, tricuspid stenosis is often inaudible but may produce a soft opening snap and a mid-diastolic rumble with presystolic accentuation. The murmur becomes louder and longer with maneuvers that increase venous return (exercise, inspiration, leg-raising, Müller maneuver) and softer and shorter with maneuvers that decrease venous return (standing, Valsalva maneuver).
Findings of tricuspid stenosis often coexist with those of mitral stenosis Mitral Stenosis Mitral stenosis is narrowing of the mitral orifice that impedes blood flow from the left atrium to the left ventricle. The usual cause is rheumatic fever. Common complications are pulmonary... read more and are less prominent. The murmurs can be distinguished clinically (see table ).
Diagnosis of Tricuspid Stenosis
Echocardiography
Diagnosis of tricuspid stenosis is suspected based on history and physical examination and confirmed by Doppler echocardiography Echocardiography This photo shows a patient having echocardiography. This image shows all 4 cardiac chambers and the tricuspid and mitral valves. Echocardiography uses ultrasound waves to produce an image of... read more 
showing a pressure gradient across the tricuspid valve. Two-dimensional echocardiography shows thickened leaflets with reduced movement and right atrial (RA) enlargement.
Severe tricuspid stenosis is characterized by
Mean forward gradient across the valve > 5 mm Hg
ECG Electrocardiography The standard electrocardiogram (ECG) provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes... read more may show RA enlargement out of proportion to RV hypertrophy and tall, peaked P waves in inferior leads and V1.
Chest x-ray Chest x-ray Chest imaging includes use of Conventional x-rays Computed tomography (CT) scanning Magnetic resonance imaging (MRI) Nuclear scanning, including positron emission tomography (PET) scanning read more may show a dilated superior vena cava and RA enlargement, indicated by an enlarged right heart border.
Liver enzymes Laboratory Tests of the Liver and Gallbladder Laboratory tests are generally effective for the following: Detecting hepatic dysfunction Assessing the severity of liver injury Monitoring the course of liver diseases and the response to treatment... read more are elevated because of passive hepatic congestion.
Cardiac catheterization Cardiac Catheterization Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries and veins. Cardiac catheterization... read more 
is rarely indicated for evaluation of tricuspid stenosis. When catheterization is indicated (eg, to evaluate coronary anatomy), findings include elevated RA pressure with a slow fall in early diastole and a diastolic pressure gradient across the tricuspid valve.
Treatment of Tricuspid Stenosis
Diuretics and aldosterone antagonists
Rarely valve repair or replacement
Evidence to guide treatment of tricuspid stenosis is scarce. Patients with symptoms who are not undergoing valve replacement or repair should receive a low-salt diet, diuretics, and aldosterone antagonists.
Patients with severe tricuspid stenosis should undergo intervention if they are symptomatic or if cardiac surgery is being done for other reasons.
Percutaneous balloon tricuspid commissurotomy might be considered for severe TS in patients who cannot undergo surgical repair but only if there is no accompanying tricuspid regurgitation.
Key Points
Tricuspid stenosis is almost always due to rheumatic fever; tricuspid regurgitation and mitral stenosis are often also present.
Heart sounds include a soft opening snap and a mid-diastolic rumble with presystolic accentuation; the murmur becomes louder and longer with maneuvers that increase venous return (eg, exercise, inspiration, leg-raising) and softer and shorter with maneuvers that decrease venous return (standing, Valsalva maneuver).
Treatment includes diuretics and aldosterone antagonists; surgical repair or replacement is rarely needed.
