Tricuspid Valve Disease

Tricuspid valve disease affects the valve between the two right heart chambers, preventing it from working properly. While it can remain silent for years, moderate to severe cases can damage the heart over time and require treatment ranging from medications to minimally invasive procedures.

Table of contents

• What Is Tricuspid Valve Disease?
• The Tricuspid Valve and How It Works
• Types of Tricuspid Valve Disease
• What Causes Tricuspid Valve Disease?
• Signs and Symptoms
• How Is It Diagnosed?
• Treatment Options
• Living with Tricuspid Valve Disease

• Right atrium
• Right ventricle
• Heart valves

What Is Tricuspid Valve Disease?

Tricuspid valve disease is a condition that occurs when the valve between the two right heart chambers doesn’t function properly^[1]. This valve is located between the right upper heart chamber, called the right atrium (where blood enters from the body), and the right lower heart chamber, called the right ventricle (which pumps blood to the lungs)^[2].

The tricuspid valve is one of four valves in the heart that help blood flow in the right direction. When this valve doesn’t work as it should, the heart must work harder to pump blood to the lungs and the rest of the body^[1]. Tricuspid valve disease often happens alongside other heart valve diseases^[1].

Mild tricuspid valve disease may not cause any symptoms or problems. However, moderate to severe cases can enlarge the heart and cause permanent damage over time^[2].

The Tricuspid Valve and How It Works

The tricuspid valve is positioned vertically between the right ventricle and the right atrium^[3]. It is made of three thin but strong flaps of tissue called leaflets or cusps. These leaflets are named by their positions: anterior, posterior, and septal. They attach to the papillary muscles of the ventricle with thin, strong cords called chordae tendineae^[3].

Every time your heart beats, the atria receive oxygen-poor blood from the body, and the ventricles contract to pump blood out. The tricuspid valve opens and closes to ensure that blood flows at the right time and in the correct direction^[3].

When the right atrium fills with blood, the tricuspid valve opens, allowing blood to flow into the right ventricle. Then the right ventricle contracts to send blood to the lungs. The tricuspid valve closes tightly so that blood does not flow backward into the right atrium^[3]. The sounds of the heart valves opening and closing are the sounds you hear in a heartbeat^[3].

This valve opens and closes in a coordinated fashion to ensure that blood flows in a forward direction from the right atrium to the right ventricle, enabling blood to be pumped efficiently from the right side of the heart to the lungs for adequate oxygenation^[4].

Types of Tricuspid Valve Disease

There are several types of tricuspid valve disease^[1][2]:

Tricuspid valve regurgitation (also called tricuspid insufficiency or a leaky tricuspid valve) is the most common form. The tricuspid valve doesn’t close properly, and blood leaks backward into the upper right heart chamber. When the valve’s leaflets don’t fully seal when the heart contracts, some of the blood that should get pushed into the pulmonary artery leaks backward into the right atrium with each heartbeat^[1][4][16].

Tricuspid valve stenosis occurs when the valve is narrowed, making it harder for blood to move between the right heart chambers. The tricuspid valve opening is too narrow or stiff, restricting blood flow between the two chambers. Over time, the right atrium can become enlarged, affecting blood flow and pressure. Tricuspid stenosis can reduce the amount of blood that circulates through the lungs and then to the rest of the body^[1][2].

Tricuspid atresia is a condition present at birth, meaning it’s a congenital heart condition (also called a congenital heart defect). The tricuspid valve isn’t formed. A solid sheet of tissue blocks the blood flow between the right heart chambers. It is a birth defect in which a baby has a solid piece of tissue where the tricuspid valve should be. The tissue limits blood flow and can affect the development of the right ventricle. It usually requires surgery^[1][2].

Ebstein anomaly is a rare heart condition present at birth. The tricuspid valve is in the wrong position and the valve’s flaps are not formed correctly^[1].

Tricuspid regurgitation can be further classified into three types: Primary (organic), where the valve itself has abnormalities that may be present from birth or develop later; Secondary (functional), where the valve is structurally normal but an underlying medical condition causes it to malfunction; and Isolated, which is similar to secondary type but occurs when atrial fibrillation specifically causes right atrial enlargement^[16].

What Causes Tricuspid Valve Disease?

There are numerous causes of tricuspid valve disease. Tricuspid regurgitation most commonly occurs in conditions which cause the right ventricle to expand or dilate, resulting in enlargement of the valve’s ring-like base^[4][6].

Several things can cause tricuspid valve disease, including^[2][4][6]:

• Heart failure, which may be a cause and consequence of tricuspid valve disease. Heart failure itself may be caused by pathology of the right or left side of the heart, for example coronary artery disease, left-sided valvular disease, and conditions which affect the muscle of the heart, known as cardiomyopathies
• Pulmonary hypertension (high blood pressure in the lung circulation), which may be caused by left-sided heart disease or lung disease, such as emphysema
• Enlarged right ventricle
• Infection, such as rheumatic fever or endocarditis (infective endocarditis)
• Rheumatic heart disease, which causes the leaflets of the valve to become thick, hardened, and less able to open widely, thus restricting forward blood flow
• Carcinoid syndrome
• Systemic health conditions, such as lupus, Marfan syndrome, or rheumatoid arthritis
• Medications, especially fenfluramine and phentermine (diet drug also known as fen-phen)
• Trauma (injury), such as damage from a heart attack, myocardial biopsy, or pacemaker
• Tumor or radiation therapy to the chest
• Congenital (present at birth) defects, such as Ebstein’s anomaly
• Degeneration of the valve’s supporting connective tissue
• Recreational drug use

Signs and Symptoms

Tricuspid valve disease may not cause any symptoms until it has become severe^[4][6]. Many people with mild tricuspid valve disease have no signs at all. Trace (also called trivial) tricuspid valve regurgitation, which means a very small amount of blood leaks backward with each heartbeat, is common and harmless, and you won’t feel any symptoms^[16].

When individuals are symptomatic, they may report^[2][4][6]:

• Fatigue or weakness
• Shortness of breath (called dyspnea)
• Decreased exercise tolerance
• Swelling (edema) of the legs, ankles, feet, or abdomen (belly)
• A pulsing or fluttering sensation in the neck or chest
• Arrhythmia (abnormal heart rhythm)
• Enlarged liver
• Skin that feels abnormally cold

Affected individuals may be noted to have a heart murmur (a whooshing sound heard with a stethoscope), an enlarged, pulsating liver, as well as a pulsating neck vein, reflecting the backflow of blood from the right side of the heart^[4][6][7].

How Is It Diagnosed?

Tricuspid valve regurgitation can occur silently and may be found when imaging tests of the heart are done for other reasons^[7][14]. To diagnose tricuspid valve disease, a healthcare provider will conduct a physical exam, which will involve^[2][8]:

• Asking you about your symptoms
• Discussing your health history and medications
• Feeling the veins in your neck
• Listening to your heart with a stethoscope (a whooshing sound called a heart murmur may be heard)

Tests to diagnose tricuspid valve disease may include^{[4][6][7][14]}:

Echocardiogram. This is the main and most common test for diagnosing tricuspid valve disease. It uses sound waves to create pictures of the beating heart. The test shows how blood flows through the heart and the heart valves, including the tricuspid valve, and evaluates the structure and function of both the heart muscle and valves. There are different types of echocardiograms:

• A standard echocardiogram is called a transthoracic echocardiogram (TTE), which creates pictures of the heart from outside the body by placing the sound device on the chest wall
• Sometimes a more detailed echocardiogram is needed to better see the tricuspid valve. This test is called a transesophageal echocardiogram (TEE), which creates pictures of the heart from inside the body. A tube and transducer are inserted into the esophagus for more detailed imaging

Electrocardiogram (ECG or EKG). This quick test records the electrical signals in the heart. It shows how the heart is beating. Electrodes assess the heart’s electrical activity^[4][6][7].

Stress tests. These tests assess the response of the heart to physical exertion, either by electrocardiography or echocardiography^[4][6].

Treatment Options

Management of tricuspid valve disease depends on the severity of the disease and symptoms as well as the underlying cause^[6]. Treatment ranges from monitoring to medications to surgery^[2][8]. Treatment may include regular health checkups, medicines, or a procedure or surgery to fix or replace the valve^[1].

Medications

Certain medications may be used in the treatment of underlying heart failure, both to relieve symptoms and prolong survival^[6]. Medications can address symptoms and help reduce complications of long-standing regurgitation, such as pulmonary hypertension^[12]. These medications include^[12]:

• Diuretics (water pills) to remove excess fluid from the body
• Antiarrhythmics
• Beta blockers
• Blood thinners

Surgical Treatment

Eligibility for surgery will be evaluated by your surgeon based on symptoms, the severity of tricuspid disease, as well as the extent to which it has resulted in heart failure^[6]. Options for surgery include tricuspid valve repair or replacement^[6].

Repair may involve insertion of a synthetic annuloplasty ring to tighten and stabilize the existing valve, or other techniques to repair the valve^[6]. When needed, the valve may be replaced with a prosthetic valve^[6].

Surgical tricuspid valve annuloplasty remains the treatment of choice for the majority of patients, especially if the operative risk is acceptable and preserved right ventricular function is present^[9].

Transcatheter (Minimally Invasive) Treatment

Several transcatheter techniques are currently available to provide alternative treatment options for patients with a very high surgical risk^[9]. These minimally invasive procedures can access the heart through the large blood vessels without traditional surgery^[12].

Transcatheter edge-to-edge repair (TEER) is a procedure that uses a clip to reduce leaking across the valve. The clip, such as the TriClip, has arms that open and close. When it is attached to the valve leaflets, it brings the leaflets of the valve together and reduces the amount of leaking^[11][20].

Advanced cardiac imaging technology is used to guide the procedure. A guidewire is inserted into a blood vessel in the leg or neck and then guided up to the heart. A special tube called a catheter then delivers instruments and devices up to the diseased valve. Once in place, the devices are deployed and implanted. Once completed, the instruments and wires are removed, and the catheter is withdrawn^[12].

Transcatheter tricuspid valve replacement (TTVR) is another minimally invasive option. Studies have shown that patients who underwent catheter-based tricuspid valve replacement experienced significant improvements^[13].

These procedures are good options for patients who are too sick or frail for traditional surgery^[12]. The clip was approved by the Food and Drug Administration in April 2024^[11]. At two years, TriClip TEER reduced the risk of heart failure hospitalization by 28% relative to medical therapy alone^[20].

Living with Tricuspid Valve Disease

How tricuspid regurgitation might affect your life depends a lot on how much your valve is leaking, as well as any other heart conditions you have^[15]. If the valve is only leaking a little, you may not feel much differently than usual. However, because it’s a lifelong condition that tends to get worse with time, your doctor will want to see you regularly and monitor how leaky the valve is, even if you feel well^[15].

At later stages, people notice having less energy. Daily tasks can take much longer. It may also be difficult to do many of the activities once enjoyed, such as working, preparing holiday meals, traveling, volunteering, taking care of others, or pursuing various hobbies^[15].

What You Can Do

To manage your condition effectively^[15][21]:

• Keep all follow-up visits and imaging tests ordered by your cardiologist and valve specialist
• Tell your doctor if symptoms get worse, such as new or increased swelling in your belly, legs, or ankles; shortness of breath; lack of energy; or weakness
• Always take medicines as prescribed. Diuretics can be difficult given frequent trips to the bathroom, but getting rid of excess fluid is important and will help you feel better
• Ask about procedures to fix the valve and whether that’s an option for you
• Bring a trusted friend or family member to your appointments as a second set of eyes and ears
• Build your support team and reach out to other people with tricuspid regurgitation to share experiences and tips

Healthy Lifestyle Changes

To maintain a healthy heart and lower the risks of heart disease, lifestyle modifications are important^[19][21]:

Eat heart-healthy foods. Adopt a healthy diet rich in fruits, vegetables, and whole grains, and low in cholesterol and saturated fats. Eat a variety of fruits, vegetables, and whole grains regularly. Change the source of protein to be plant-based, such as nuts and legumes, or fish and seafood, instead of animal meats. Reduce salt (sodium), sugar, and alcohol intake. Avoid processed foods, especially processed meat such as sausage, ham, and bacon. Anything sold in a jar, a can, or a bag tends to be high in salt^[15][19][21].

Be active. Regular moderate to high-intensity exercises such as dancing, running, jogging, or speed walking can improve your physical fitness and mental health. It is recommended for adults to exercise for 150-300 minutes a week at moderate to high intensity for aerobic/cardio type. Ask your doctor what type and level of exercise is safe for you. Let your doctor know if your ability to exercise changes^[19][21].

Try to quit or cut back on using tobacco and other nicotine products. This includes smoking and vaping. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. Try to avoid secondhand smoke too^[21].

Stay at a weight that’s healthy for you. Talk to your doctor if you need help with this. Balance energy intake and expenditure and avoid overeating^[19][21].

Dental care. Take care of your teeth and gums. Get regular dental checkups, at least one to two visits per year. According to research, people who brush their teeth twice a day for a minimum of two minutes have a three-fold lower risk of developing heart disease. Good dental health is important because bacteria can spread from infected teeth and gums to the heart valves^[19][21].

Avoid infections. Get the flu vaccine every year. Get a pneumococcal vaccine. Stay up to date on your COVID-19 vaccines^[21].

Try to get seven to nine hours of sleep each night. Manage other health problems. If you think you may have a problem with alcohol or drug use, talk to your doctor^[21].