Tricuspid Stenosis Treatment & Management

In the treatment of tricuspid stenosis, medical care consists of assessment and treatment of the underlying cause of the valvular pathology, as follows:

• 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.

Inpatient care consists of treating the underlying precipitating condition. For acute bacterial endocarditis or rheumatic causes, antibiotic therapy is indicated until the acute phase has resolved. Then, valve surgery can be considered, if indicated.

After valve replacement, inpatient care consists of regulating the anticoagulation and treating postoperative arrhythmias until stability has been achieved. After valve replacement, adjust anticoagulation to an international normalized ratio (INR) of 3-4 because of the low-pressure and low-flow state of the right side. Because of the high risk of thrombosis in this low-pressure system, some authors recommend warfarin therapy for bioprosthetic or mechanical valves.

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. Note the following:

• 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. ^[8] Reddy and colleagues report on the successful outcome of percutaneous valvuloplasty to treat severe bioprosthetic tricuspid valve stenosis in the setting of infective endocarditis. Their patient, a 29-year-old male with a history of intravenous drug use and two previous bioprosthetic tricuspid valve placements, was considered extremely high risk for redo valve replacement surgery. The investigators conclude that interventional treatment of prosthetic valvular stenosis in the setting of endocarditis is a reasonable therapy to use when open surgical repair is prohibitively risky with regard to mortality. ^[9]

• 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.

• In selected patients with prior tricuspid valve surgery and significant stenosis of a bioprosthetic tricuspid valve or a right atrium to right ventricle (RA-to–RV) conduit, percutaneous tricuspid valve replacement may be an option. ^[10]

• Transcatheter valve-in-valve implantation with either the Melody or Edwards SAPIEN valve may be a potential procedure for patients with significant tricuspid stenosis, significant tricuspid regurgitation, or a mixed lesion and a failing bioprosthesis. ^{[11, 12]}

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.

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 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.

For those cases in which intravenous drug use or bacterial endocarditis was the precipitating event, emphasize careful dental hygiene. Maximize drug detoxification efforts. Of course, do not forget that routine antibiotic coverage should be administered for prevention of endocarditis.

Outpatient care consists of routine follow-up care with echocardiography studies to assess valvular function. Check the INR monthly to regulate anticoagulation. In those instances in which the tricuspid stenosis is secondary to some other process (eg, carcinoid, tumor), consider continual surveillance of the underlying disease state.