eMedicine Specialties > Cardiology > Valvular Heart Disease
Tricuspid Stenosis: Treatment & Medication
Updated: Jul 29, 2008
- Overview
- Differential Diagnoses & Workup
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Treatment
Medical Care
In the treatment of tricuspid stenosis, medical care consists of assessment and treatment of the underlying cause of the valvular pathology.
- Treat bacterial endocarditis with the appropriate antibiotics as determined by the sensitivity of the organisms cultured.
- Medically address cardiac arrhythmias depending on their characterization.
- Decreasing right atrial volume overload with diuresis and salt restriction helps decrease symptoms and improve hepatic function.
Surgical Care
Tricuspid stenosis remains a surgical disease and requires either commissurotomy or replacement of the valve if right heart failure or low cardiac output has resulted. Surgery is rarely performed solely on the tricuspid valve; it is usually performed in combination with mitral and/or aortic valve disease repair. (6)
- With tricuspid valve replacement, the risk of thrombosis is significant and many surgeons advise warfarin therapy for either mechanical or bioprosthetic valve placement.
- Percutaneous balloon valvuloplasty has been used successfully, as long as concomitant regurgitation is not significant.
- The therapy chosen depends on the structure of the valve and the degree of deformity encountered.
- When possible, excise intracavitary pathology, whether it be tumors or other structural abnormalities.
- Redundant portions of the dilated right atrium can be excised during the same procedure for restoring the atrium back to normal size.
Consultations
- Consultation with infectious disease specialists may be appropriate if the stenosis is secondary to an infectious process.
- An endocrinologist may be of assistance if carcinoid syndrome or an inborn error of metabolism is the cause of the pathology.
Diet
- No specific dietary restrictions are necessary before therapy.
- Fluid and sodium restriction is prudent if signs of venous congestion are present.
- If a valve replacement is undertaken and the patient must be anticoagulated, dietary instructions must be provided regarding those foods that interfere with anticoagulation and are rich in vitamin K.
Activity
- Activity is usually self-limited by the patient because of easy fatigability secondary to oxygen deprivation.
- Once the pathology has been corrected, no activity restrictions are necessary.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antiarrhythmic agents
Alter the electrophysiologic mechanisms responsible for arrhythmia.
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects and indirect effects on the cardiovascular system. Acts directly on cardiac muscle and increases myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Adult
0.125-0.375 mg PO qd
Pediatric
Digitalization in infants and children not generally recommended; suggested doses are as follows
TDD:
Premature infants: 0.02-0.03 mg/kg if tablet; 0.015-0.025 mg/kg if capsule, IV, or IM in divided doses
Full-term infants: 0.025-0.035 mg/kg if tablet; 0.02-0.03 mg/kg if capsule, IV, or IM in divided doses
1-24 months: 0.035-0.06 mg/kg if tablet; 0.03-0.05 mg/kg if capsule IV, or IM in divided doses
2-5 years: 0.03-0.04 mg/kg if tablet; 0.025-0.035 mg/kg if capsule, IV, or IM in divided doses
5-10 years: 0.02-0.035 mg/kg if tablet; 0.015-0.030 mg/kg if capsule, IV, or IM in divided doses
>10 years: 0.01-0.015 mg/kg if tablet; 0.008-0.012 mg/kg if capsule, IV, or IM in divided doses
May accomplish digitalization by giving one half TDD in first dose followed by 2 doses that are one fourth TDD given at 8-12h intervals
Maintenance dose:
Premature infants: 0.005-0.0075 mg/kg if tablet; 0.004-0.006 mg/kg if capsule, IV, or IM divided q12h
Full-term infants: 0.006-0.010 mg/kg if tablet; 0.005-0.008 mg/kg if capsule, IV, or IM divided q12h
1-24 months: 0.010-0.015 mg/kg if tablet; 0.0075-0.012 mg/kg if capsule IV, or IM divided q12h
2-5 years: 0.0075-0.010 mg/kg if tablet; 0.006-0.009 mg/kg if capsule, IV, or IM divided q12h
5-10 years: 0.005-0.010 mg/kg if tablet; 0.004-0.008 mg/kg if capsule, IV, or IM divided q12h
>10 years: 0.0025-0.005 mg/kg if tablet; 0.002-0.003 mg/kg if capsule, IV, or IM qd or divided q12h
Medications that may increase levels include alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, oral amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil
Medications that may decrease serum levels include aminoglutethimide, antihistamines, cholestyramine, neomycin, penicillamine, aminoglycosides, oral colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, and procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid
Documented hypersensitivity; beriberi heart disease; idiopathic hypertrophic subaortic stenosis; constrictive pericarditis; carotid sinus syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypokalemia may reduce positive inotropic effect of digitalis; IV calcium may produce arrhythmias in digitalized patients; hypercalcemia predisposes to digitalis toxicity, and hypocalcemia can make digoxin ineffective until serum calcium levels are normal; magnesium replacement therapy must be instituted in patients with hypomagnesemia to prevent digitalis toxicity; patients diagnosed with incomplete AV block may progress to complete block when treated with digoxin; exercise caution in hypothyroidism, hypoxia, and acute myocarditis
Anticoagulants
Used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.
Warfarin (Coumadin)
Interferes with hepatic synthesis of vitamin K–dependent coagulation factors. Tailor dose to maintain an INR in the range of 2-3.
Adult
5-15 mg/d PO for 2-5 d; adjust dose according to desired INR
Pediatric
0.05-0.34 mg/kg/d PO; adjust dose according to desired INR
Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate
Medications that may increase anticoagulant effects include oral antibiotics, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen, and sulindac
Documented hypersensitivity; severe liver or kidney disease; open wounds or GI ulcers
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis
More on Tricuspid Stenosis |
| Overview: Tricuspid Stenosis |
| Differential Diagnoses & Workup: Tricuspid Stenosis |
 Treatment & Medication: Tricuspid Stenosis |
| Follow-up: Tricuspid Stenosis |
| Multimedia: Tricuspid Stenosis |
| References |
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References
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Further Reading
Keywords
tricuspid stenosis, tricuspid valve, rheumatic heart disease, mitral stenosis, carcinoid, Ebstein anomaly, tricuspid valve dysfunction, myocardium aberrations, stenotic tricuspid valves, rheumatic fever, carcinoid syndrome, endocarditis, endomyocardial fibrosis, lupus, congenital tricuspid atresia, rheumatic fever, congenital tricuspid stenosis, atrial fibrillation, peripheral edema, ascites, congenital abnormalities, metabolic abnormalities, enzymatic abnormalities, active infective endocarditis, rheumatic tricuspid stenosis, carcinoid heart disease, infective endocarditis, Fabry disease, giant blood cysts, supravalvular obstruction from congenital diaphragms, intracardiac tumor, extracardiac tumor, thrombosis, emboli, large endocarditis vegetations
