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Tricuspid valve stenosis is a condition in which the valve that allows passage between the upper and lower right chambers of the heart thickens, loses its flexibility, narrows, and prevents blood from flowing forward comfortably. When this structure, which is critically important for a healthy circulatory system, becomes impaired, the process of pumping deoxygenated blood returning from the body to the lungs is disrupted. This mechanical obstruction in blood flow continuously increases the workload of the heart and causes fatigue throughout the body. This heart valve problem, which directly affects quality of life, can be treated extremely safely with today’s modern and innovative medical approaches when detected early.
| What Is Tricuspid Valve Stenosis? | Tricuspid valve stenosis is a heart valve disease that occurs when narrowing of the tricuspid valve located between the right atrium and the right ventricle makes it difficult for blood to pass from the right atrium to the right ventricle. |
| Function | The tricuspid valve allows blood to pass in one direction from the right atrium to the right ventricle and prevents backward leakage. |
| Prevalence | It is a rare heart valve disease and is usually found together with other valve diseases. |
| Most Common Cause | The most common cause is rheumatic heart disease. Less commonly, it may develop due to congenital anomalies, a tumor on the valve, infection, radiotherapy, systemic diseases, or pacemaker electrodes. |
| Risk Factors | A history of acute rheumatic fever, rheumatic heart disease, congenital heart diseases, infective endocarditis, systemic inflammatory diseases, and advanced age may create a risk. |
| Symptoms | Weakness, easy fatigue, abdominal swelling, edema in the legs, prominent neck veins, liver enlargement, right upper abdominal pain, and reduced exercise capacity may occur. |
| Advanced-Stage Findings | In advanced cases, widespread edema, ascites (fluid accumulation in the abdomen), severe right-sided heart failure, and rhythm disorders may develop. |
| Physical Examination Findings | Distention of the neck veins, liver enlargement, peripheral edema, and a characteristic murmur in the tricuspid valve area of the heart may be detected. |
| Diagnostic Methods | Echocardiography is the primary diagnostic method. Doppler echocardiography, electrocardiography (ECG), chest X-ray, cardiac MRI, CT, and cardiac catheterization may be used when necessary. |
| Importance of Echocardiography | It is the most important examination for evaluating the valve opening, pressure gradient, valve structure, and other accompanying valve diseases. |
| Grading of the Disease | It is evaluated as mild, moderate, and severe tricuspid valve stenosis. Classification is made according to echocardiographic findings. |
| Treatment Goals | The goals are to reduce symptoms, preserve right heart function, prevent complications, and improve quality of life. |
| Medication Treatment | Diuretics may be used to reduce edema. Treatment is administered for the underlying causes. Medications do not eliminate valve stenosis but may relieve symptoms. |
| Interventional Treatment | Balloon valvuloplasty may be performed in suitable patients. However, it is preferred in selected cases. |
| Surgical Treatment | Valve repair or valve replacement may be required in cases of severe stenosis and significant symptoms. It may be performed together, especially in patients scheduled for another valve surgery. |
| Complications | Right-sided heart failure, atrial fibrillation, liver dysfunction, venous circulation disorders, and a marked reduction in quality of life may occur. |
| Follow-Up | The progression of the disease is monitored through regular cardiology checkups and echocardiography at certain intervals. |
| Lifestyle Recommendations | Reducing salt consumption, maintaining fluid balance in accordance with the doctor’s recommendation, regular exercise in suitable patients, avoiding smoking, and controlling chronic diseases are recommended. |
| Condition During Pregnancy | Mild cases are generally well tolerated. Cardiology evaluation before pregnancy is required in moderate and severe stenosis. |
| Prognosis | It varies depending on the cause and severity of the disease, other accompanying heart diseases, and the response to treatment. Long-term outcomes can be improved with early diagnosis and appropriate treatment. |
| When Should Emergency Care Be Sought? | Emergency medical evaluation is required when sudden shortness of breath, loss of consciousness, severe palpitations, rapidly developing widespread edema, chest pain, or severe weakness occurs. |
What Is Tricuspid Valve Stenosis?
We can think of the heart as a very powerful pump with four separate chambers that works without stopping. The right side of this pump is responsible for collecting blood returning from all parts of the body after becoming deoxygenated and reduced in oxygen. This blood returning from the body first fills the upper right chamber of the heart, namely the right atrium. When the right atrium is filled, the blood must pass into the lower chamber, namely the right ventricle. The function of the right ventricle is to send this blood to the lungs for oxygenation. The passageway between these two chambers is called the tricuspid valve.
In a healthy heart, this valve opens wide enough to allow blood to flow downward easily and closes tightly after the blood passes to prevent it from leaking backward. Under normal conditions, the opening of this valve is quite wide, and blood flows into the lower chamber without encountering any resistance. The pressure difference between the two chambers is also extremely low.
However, due to certain health problems, the leaflets of this valve may thicken, stiffen, or adhere to one another. When the valve loses its flexibility, it can no longer open properly, and the area through which blood can pass narrows. This condition is called valve stenosis. When the valve narrows, the upper right atrium has to make much more effort than normal to push blood into the lower chamber. This condition causes a continuous increase in pressure in the upper chamber. If the narrowing in the valve falls below a certain level, this pressure does not remain only in the heart but is reflected backward into the body’s main veins. Blood trying to return to the heart from the lower parts of the body and internal organs cannot overcome this high-pressure barrier in the heart and begins to pool behind it. This pooling makes the functioning of the organs more difficult and produces the clinical picture of the disease. This condition, which was often overlooked in previous years because attention was focused only on the left heart valves, can now be understood much more clearly with advanced imaging methods.
What Are the Degrees of Tricuspid Valve Stenosis?
To understand how far the disease has progressed and to plan the appropriate timing of treatment, the valve opening and the pressure difference it creates in the heart are divided into certain stages. This classification is generally performed using echocardiography devices that examine the heart with ultrasound waves.
| Disease Severity | General Characteristics and Observed Findings |
| Mild | A certain degree of narrowing has begun in the valve area, but the heart tolerates this condition easily. The pressure difference is low. Patients usually do not feel any discomfort in their daily lives. |
| Moderate | The valve opening has narrowed significantly. Difficulty in blood passage begins. Individuals may feel weakness, especially when climbing a hill or walking briskly. Mild swelling may be observed. |
| Severe | The valve area has become significantly smaller, and the pressure difference has increased considerably. Fluid pooling begins in the organs. Prominent symptoms that reduce quality of life, restricted movement, and difficulty in organ functions are present. |
This staging table guides when treatment should be initiated. In the early stages, the heart may conceal the problem by demonstrating a great ability to adapt. However, in advanced stages, these compensatory mechanisms become insufficient, and the body begins to give warning signals.
Which Factors Cause Tricuspid Valve Stenosis?
There are many different medical conditions that cause the tricuspid valve to lose its flexibility and narrow. These conditions generally involve processes that develop slowly over the years.
Common causes include:
- Rheumatic fever
- Pacemaker leads
- Carcinoid syndrome
- Congenital anomalies
- Connective tissue diseases
- Chest radiotherapy
Rheumatic fever generally occurs when the body’s immune system reacts to the heart valves after throat infections experienced during childhood or adolescence. Years later, this condition may cause the valve leaflets to thicken and adhere to one another. Rheumatic involvement generally also affects the valves on the left side of the heart.
Another increasingly common cause today is medical devices. The leads of pacemakers or shock devices implanted to regulate heart rhythm are passed through the tricuspid valve as they are delivered to the heart through the veins. These leads, which come into contact with the valve during every heartbeat for years, may sometimes damage the leaflets or restrict their movement, creating the conditions for stenosis.
Carcinoid syndrome is a condition in which substances secreted by certain tumors in different parts of the body reach the heart through the bloodstream and form hard, calcified layers on the valve. Although congenital heart diseases are rare, they may cause problems at older ages because the valve has a developmentally different structure. In addition, large infected clots forming in the heart or radiotherapy treatments received in the past may also disrupt the natural structure of the valve.
What Symptoms Does Tricuspid Valve Stenosis Cause?
Because the atrium on the right side of the heart has some capacity to stretch, the disease generally progresses insidiously for years. Individuals may not feel any problems for a long time. However, when the narrowing in the valve exceeds a certain limit, noticeable complaints begin as blood pools backward.
General clinical symptoms include:
- Weakness
- Edema in the feet and legs
- Fluid accumulation in the abdomen
- Loss of appetite
- Easy fatigue
- Feeling of palpitations
As a result of blood being unable to pass comfortably from the right atrium to the ventricle, a sufficient amount of blood cannot be pumped to the lungs and therefore to the body. Because this condition reduces oxygen delivery to the muscles, it decreases the person’s exercise capacity; even the slightest daily activity causes fatigue.
On the other hand, the pressure created in the veins by blood that cannot enter the heart is reflected in the lower parts of the body. Due to this high pressure, fluid in the blood leaks outside the vessels. With the effect of gravity, pitting edema that leaves an indentation when pressed with a finger first occurs in the ankles and legs. As the disease progresses, fluid begins to accumulate in the abdominal cavity. Pooling in the vessels around the liver and intestines disrupts the functioning of the digestive system. The person feels full very quickly after eating and experiences abdominal fullness and loss of appetite.
In addition, because the upper chamber of the heart is constantly exposed to high pressure, it becomes excessively enlarged over time. This enlargement adversely affects the heart’s natural electrical system and facilitates the development of rhythm disorders called atrial fibrillation, in which the heart beats irregularly and rapidly. Patients generally describe this condition as an uncomfortable feeling of palpitations.
Why Is the Risk of “Being Too Late” Important in the Treatment of Tricuspid Valve Stenosis?
In the field of heart health, the timing of diseases is at least as critical as the treatment itself. The concept of “being too late,” which is considered very important in the medical world regarding intervention on the right heart valves, is related to the durability of the heart muscle tissue.
Because the left side of the heart pumps blood throughout the body, it has very thick and strong muscles. However, because the right side sends blood only to the nearby lungs, it structurally consists of a thinner muscle group accustomed to lower pressures. When long-standing stenosis is present in the tricuspid valve, the right ventricle cannot receive enough blood and, if pulmonary hypertension is also present, it must continuously resist the high pressure ahead of it. This stress lasting for years tires and weakens the thin right heart muscle and causes it to lose its flexibility.
If the patient’s treatment process is delayed too much, the right ventricular muscle may suffer damage that is difficult to reverse. At such a stage, even if the stenosis in the valve is successfully eliminated and the valve is completely opened using technological methods, a new and major problem may arise. When the valve opens, blood that has accumulated above for years suddenly flows into the lower chamber at great speed. However, the right ventricular muscle in the lower chamber may be so exhausted that it cannot find the strength to propel this suddenly increased blood load toward the lungs. This condition causes adaptation problems after the procedure and places strain on the heart.
The same applies to the liver. Years of blood pooling in the liver may impair the structure of the organ and create the conditions for irreversible hardening called fibrosis. For these reasons, the aim is to detect the disease and perform the intervention at the correct time before the heart muscle loses its resistance and permanent fatigue begins in the internal organs.
Which Methods Are Used to Diagnose Tricuspid Valve Stenosis?
Advanced imaging technologies are used to confirm the presence of the disease, examine the condition of the valve, and select the most appropriate treatment approach.
The methods used in diagnosis include:
- Transthoracic echocardiography
- Transesophageal echocardiography
- Cardiac magnetic resonance imaging
- Cardiac catheterization
Transthoracic echocardiography is the classic ultrasound procedure performed from the surface of the chest. This painless and radiation-free method broadly shows the structure of the valve, how much it has thickened, and the speed of blood flow through it. In most cases, the initial diagnosis is made using this method.
However, if an intervention on the valve using devices from outside the body is planned, clearer and millimetric images are required. At this point, transesophageal echocardiography is used. In this procedure, a thin tube with an ultrasound camera at its tip is passed down through the esophagus. Because the esophagus is located immediately behind the heart, three-dimensional and extremely high-resolution images of the heart valves are obtained without the rib cage or lungs interfering. The valve area is measured, and its suitability for nonsurgical methods is evaluated.
Cardiac magnetic resonance imaging is another sensitive technology that analyzes in detail the size of the right ventricle, how healthy the muscle tissue is, and how much blood it can pump. When considered necessary, cardiac catheterization may be performed by reaching the heart with a small tube through the groin and directly measuring the pressures.
What Is the Balloon Valvuloplasty Method Used for Tricuspid Valve Stenosis?
If there is no severe calcification in the heart valve, if excessive backward leakage of blood does not accompany the stenosis, and if the patient has anatomical characteristics suitable for the procedure, the nonsurgical treatment option is balloon valve dilation, also known as percutaneous balloon valvuloplasty. Because this method is performed without opening the rib cage or putting the patient to sleep, the burden on the body is extremely low.
The procedure is performed under local anesthesia in special angiography laboratories.
What Are the New-Generation Device Treatments for Tricuspid Valve Stenosis?
In cases where the balloon procedure is unsuitable, the shape of the valve is severely impaired, but the patient cannot tolerate open heart surgery because of age or additional diseases, innovative device treatments offered by medical technology are used. Various transcatheter procedures performed through the groin now stand out in patients who were considered untreatable in the past.
Nonsurgical method options include:
- Edge-to-edge clipping
- Transcatheter valve replacement
- Caval valve implantation
Edge-to-edge clipping methods may be preferred in cases where the valve cannot close completely and blood leaks backward together with stenosis. Just as the torn part of a garment is held together with a clip, suitable parts of the valve are captured and attached to one another using devices sent from the groin to bring the leakage under control. New-generation systems also include designs that place a spacer between the leaflets to reduce tension.
In transcatheter valve replacement, if the original valve cannot be repaired, a new prosthetic valve produced from biological materials is delivered to the heart in a folded state at the tip of a catheter. This new valve, placed directly inside the old valve, is expanded by inflation or self-expansion, compresses the old diseased tissue, and immediately begins to function as a new passageway.
Caval valve implantation is a different strategy applied in patients for whom touching the valve itself would be too risky. Because the problem is the backward transmission of blood to the organs due to the narrowed valve, special valves are placed at the ends of the main veins entering the heart. In this way, blood cannot flow back toward the organs and legs, and the aim is to largely prevent exhausting complaints such as abdominal fluid accumulation and edema.
How Is the Valve-in-Valve Procedure for Tricuspid Valve Stenosis Performed?
Some patients previously underwent open heart surgery because of tricuspid valve disease and had a biological valve made from animal tissue implanted in the heart to reduce the risk of clot formation. However, just like living tissues, these biological valves may wear out, become calcified, and narrow again over time. Reopening the chest for a second operation to replace this worn valve carries very high risks because the patient is now older. At this point, the “Valve-in-Valve” procedure, also known as Tricuspid Valve-in-Valve or TViV, provides an extremely innovative alternative.
The general steps of this procedure are as follows:
- Imaging and measurement
- Vascular access
- Guidewire placement
- Crossing the old valve
- Positioning the new valve
- Expansion with a balloon
- Post-procedure checks
The process begins with examination of previous surgical reports and tomography images. The millimetric size of the worn valve is determined, and the size of the new valve that will fit most appropriately inside it is selected. On the day of the procedure, access is obtained through the right femoral vein while the patient is under local anesthesia.
By following the images on the screen, thin wires with soft tips are slowly advanced through the old and deteriorated surgical valve into the lower chamber. During this passage, the wires are advanced with special care to avoid damaging the heart. This soft wire is then replaced with a thick and rigid wire that will carry the valve.
If the patient’s old valve appears dark on X-ray, a balloon is first inflated to determine the exact implantation site of the valve. The new biological valve in its folded state is then advanced over this wire to the level of the old valve. Very precise alignment is performed so that thirty percent remains in the upper chamber and seventy percent remains in the lower chamber. After the position is confirmed, the delivery balloon is inflated; the new valve expands, anchors firmly inside the old valve, and immediately begins to function. After confirming that the pressures have returned to normal, the procedure is completed by placing a suture at the access site in the groin. This method, which does not expose patients to the stress of a second operation, allows them to leave the hospital walking within a very short time.
In Which Situations Is Open Heart Surgery Preferred for Tricuspid Valve Stenosis?
Despite the enormous convenience and rapid recovery offered by interventional vascular treatments, surgical intervention, namely open heart surgery, remains the most valid and appropriate method for certain anatomical problems in the heart. The valve structure or accompanying diseases of every patient may not be suitable for nonsurgical methods.
If the problem in the patient’s heart is not limited to the tricuspid valve, for example, if there are also very serious disorders in the aortic or mitral valve and open surgery is mandatory for these valves, surgeons prefer to intervene directly on the tricuspid valve in the same session while the chest is already open. In this way, all mechanical problems in the heart are repaired at the same time.
In addition, if large, mobile clusters of bacteria and clots known as vegetations have formed on the heart valves due to severe infections, devices inserted through the vessels may dislodge these clots and send them into the lungs. In such cases, it is vitally important for the surgeon to see the area directly and clean it completely. In surgical procedures, the primary goal is always to repair the original valve by sewing a supportive ring around it. However, if the tissue has become completely hardened and lost its shape, the old valve is cut out and removed, and a brand-new mechanical or biological prosthetic valve is sewn in its place. During this process, surgeons work with extreme precision down to the millimeter to avoid damaging the heart’s electrical system.
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
