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Tricuspid Valve Disease (Stenosis & Regurgitation)

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Tricuspid Valve Disease (Stenosis & Regurgitation)

Also called

narrowing & Leaky Tricuspid Valve

ICD-10

I36.2 + I07.0

Specialty

Cardiology

Onset

chronic

Reviewed

June 2026

On This Page

Overview

Tricuspid valve disease affects the tricuspid valve, which lies between the right atrium and right ventricle. It includes:

  • Tricuspid stenosis (TS): Narrowing of the tricuspid valve, which reduces blood flow from the right atrium to the right ventricle. It is extremely rare.
  • Tricuspid regurgitation (TR): Failure of the tricuspid valve to close properly, causing backflow of blood from the right ventricle into the right atrium during systole.

Etiology & Risk Factors

1. Tricuspid Stenosis (TS)

Most common causes:

  • Rheumatic fever (most common)

  • Infective endocarditis (especially in IV drug users)

2. Tricuspid Regurgitation (TR)

Common causes:

  • Right ventricular dilation (e.g., right-sided heart failure)

  • Pressure overload of the right ventricle

  • Pulmonary hypertension (e.g., cor pulmonale, secondary to mitral stenosis)

  • Left-sided heart failure

  • Infective endocarditis (especially in IV drug users)

  • Rheumatic fever

  • Carcinoid syndrome

  • Connective tissue disorders (e.g., Marfan syndrome)

General Risk Factors (for Tricuspid Valve Disease)

  • History of rheumatic fever

  • Infective endocarditis

  • Intravenous (IV) drug use

  • Pulmonary hypertension

  • Right-sided heart failure

  • Left-sided heart failure

  • Connective tissue disorders (e.g., Marfan syndrome)

  • Carcinoid syndrome

Pathophysiology

1. Tricuspid Stenosis (TS)

  • Narrowing of the tricuspid valve obstructs blood flow from the right atrium (RA) to the right ventricle (RV) during diastole.

  • This causes:

    • Increased right atrial pressure

    • Systemic venous congestion

    • Reduced RV filling

    • Decreased cardiac output

    • Eventually right-sided heart failure

Simple Flow:
Tricuspid valve narrowing → ↓ RA → RV blood flow → ↑ Right atrial pressure → Systemic venous congestion → Right-sided heart failure

2. Tricuspid Regurgitation (TR)

  • Incomplete closure of the tricuspid valve allows blood to flow back from the RV into the RA during systole.

  • This causes:

    • Right atrial volume overload

    • Right ventricular volume overload

    • Systemic venous congestion

    • Progressive right-sided heart failure

Simple Flow:
Tricuspid valve fails to close → Blood regurgitates into RA → RA & RV volume overload → Systemic venous congestion → Right-sided heart failure

Clinical Presentation

  1. Tricuspid Stenosis (TS)

    Symptoms

    • Fatigue

    • Exercise intolerance

    • Symptoms of right-sided heart failure

      • Leg swelling (peripheral edema)

      • Abdominal swelling (ascites)

    Examination

    • Delayed diastolic murmur heard best at the left lower sternal border (4th left intercostal space).

    • May have a presystolic crescendo murmur.

    Tricuspid Regurgitation (TR)

    Symptoms

    • Fatigue

    • Exercise intolerance

    • Symptoms of right-sided heart failure

      • Peripheral edema

      • Ascites

    Examination

    • Holosystolic murmur heard best at the left lower sternal border (4th left intercostal space).

    • Carvallo sign: the murmur becomes louder during inspiration.

History Taking

  • Symptoms

    • “Do you get short of breath?”

    • “Do you feel tired more easily than before?”

    • “Do you have chest pain?”

    • “Do you feel your heart racing or skipping beats (palpitations)?”

    • “Have you ever fainted or felt dizzy?”

    Symptoms of Right-Sided Heart Failure

    • “Have you noticed swelling in your legs or ankles?”

    • “Has your abdomen become swollen?”

    • “Have you gained weight because of fluid retention?”

    Risk Factors

    • “Have you ever had rheumatic fever?”

    • “Have you had infective endocarditis?”

    • “Do you have a history of heart failure or pulmonary hypertension?”

    • “Do you use intravenous (IV) drugs?”

    • “Have you ever been told you have a heart valve problem?”

Tricuspid Stenosis Vs Tricuspid Regurgitation

Tricuspid Stenosis vs Tricuspid Regurgitation

BOTH ARE TRICUSPID VALVE LESIONS BUT WITH OPPOSITE HAEMODYNAMICS Tricuspid stenosis (TS) obstructs RA-to-RV flow → right atrial pressure/volume overload. Tricuspid regurgitation (TR) allows backflow into the RA during systole → right atrial & ventricular volume overload. TR is far more common; isolated TS is rare and usually rheumatic.
Tricuspid Stenosis (TS)
MechanismObstruction to forward flow across the tricuspid valve from RA to RV, mainly in diastole.
Most common causeRheumatic heart disease (almost always with mitral involvement). Rare causes: carcinoid syndrome, congenital, pacemaker lead-related, endocarditis vegetation.
Haemodynamic effectRA pressure/volume overload → RA enlargement → systemic venous congestion.
VS
Tricuspid Regurgitation (TR)
MechanismBackflow of blood from RV into RA during systole due to valve incompetence.
Most common causeFunctional/secondary — RV/annular dilation from pulmonary hypertension or left heart disease. Primary causes: rheumatic, endocarditis, carcinoid, Ebstein anomaly, pacemaker lead, prolapse.
Haemodynamic effectRA & RV volume overload → progressive RV dilation/dysfunction → systemic venous congestion.
Feature Tricuspid Stenosis Tricuspid Regurgitation
Murmur Diastolic rumble at left lower sternal border, increases with inspiration (Rivero-Carvallo-like augmentation) Holosystolic at left lower sternal border/subxiphoid, increases with inspiration (true Rivero-Carvallo sign)
JVP findings Giant "a" wave (forceful RA contraction against obstruction); slow "y" descent Prominent/giant "v" wave (CV wave); rapid "y" descent; may see systolic pulsation of liver
Pulse character Normal arterial pulse; low cardiac output if severe Normal; pulsatile liver, peripheral oedema common
Key echo finding Diastolic pressure gradient across TV (mean gradient ≥5 mmHg suggests significant TS); restricted leaflet motion; doming Color Doppler regurgitant jet; vena contracta, PISA/EROA, RA/RV dilation, systolic flow reversal in hepatic veins (severe)
Right heart chamber effect RA dilation predominates; RV often normal/small initially RA and RV dilation; progressive RV dysfunction
Common associations Mitral stenosis (rheumatic), carcinoid syndrome Pulmonary hypertension, left heart failure, atrial fibrillation, pacemaker/ICD leads
Definitive treatment Balloon valvuloplasty (if pliable, non-calcified) or surgical repair/replacement Treat underlying cause (PHTN, LV disease); diuretics for symptoms; surgical repair/replacement or transcatheter repair if severe/symptomatic
Tricuspid Stenosis — Clinical Picture
Symptoms — fatigue, peripheral oedema, ascites, hepatic congestion; dyspnea less prominent than left-sided lesions
Signs — giant "a" wave in JVP, hepatomegaly, ascites, peripheral oedema
Severity marker — mean diastolic gradient ≥5 mmHg or valve area <1 cm² considered significant
ECG — tall, peaked P waves (P pulmonale) reflecting RA enlargement
Tricuspid Regurgitation — Clinical Picture
Symptoms — fatigue, abdominal distension/ascites, peripheral oedema, anorexia (gut congestion)
Signs — prominent "v" wave/CV wave, pulsatile hepatomegaly, ascites, peripheral oedema, possible right heart failure
Severity markers — vena contracta ≥0.7 cm, EROA ≥0.40 cm², hepatic vein systolic flow reversal → severe
Prognosis — severe TR independently associated with worse survival, even when "functional"

Investigations

  • 1. Transthoracic Echocardiography (TTE) – Gold Standard

    • First-line investigation

    • Assesses:

      • Valve anatomy and morphology

      • Severity of tricuspid stenosis (TS) or tricuspid regurgitation (TR)

      • Cardiac structure and hemodynamics

    2. ECG

    • Assesses:

      • Cardiac rhythm

      • Signs of ventricular hypertrophy

    3. Chest X-ray

    • Evaluates:

      • Pulmonary congestion

      • Other lung pathology

    4. Advanced Investigations (if needed)

    • Transesophageal echocardiography (TEE) – better assessment of valve anatomy and complications

    • Cardiac MRI – assesses structural heart disease

    • Cardiac catheterization – evaluates valve hemodynamics and cardiac pressures

    • Exercise stress testing – if symptoms are unclear

Diagnosis

  • Diagnostic Approach

    • Suspect TS or TR based on:

      • Clinical symptoms

      • Characteristic heart murmur on examination

    • Confirm the diagnosis with Transthoracic Echocardiography (TTE).

    Physical Examination Findings

    • Tricuspid Stenosis (TS):

      • Delayed diastolic murmur at the left lower sternal border (4th left intercostal space)

    • Tricuspid Regurgitation (TR):

      • Holosystolic murmur

      • Carvallo sign: murmur becomes louder with inspiration

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Management

1. Medical (Supportive) Management

  • Treat the underlying cause (e.g., heart failure, pulmonary hypertension, infective endocarditis).

  • Manage heart failure symptoms.

  • Monitor disease progression with:

    • Regular history and physical examination

    • Periodic transthoracic echocardiography (TTE)

  • Consider endocarditis prophylaxis when indicated.

  • Secondary prevention of rheumatic fever if appropriate.

  • Anticoagulation if indicated (e.g., after prosthetic valve replacement).

2. Interventional/Surgical Management

Patients with severe and/or symptomatic valve disease should be referred for intervention.

Valve Repair

  • Valve reconstruction (annuloplasty) to restore valve function.

  • Valvuloplasty (balloon or surgical commissurotomy) for valvular stenosis.

Valve Replacement

  • Surgical valve replacement if repair is not feasible.

  • Choice of mechanical or bioprosthetic valve depends on:

    • Age

    • Comorbidities

    • Ability to take long-term anticoagulation

    • Patient preference

3. Acute Decompensation 

Patients presenting with:

  • Acute heart failure

  • Cardiogenic shock

  • Severe arrhythmias

require:

  • Urgent stabilization

  • Immediate cardiology consultation

  • Consideration of urgent valve intervention

Complications

    • Right-sided heart failure
    • Progressive systemic venous congestion
    • Cardiac arrhythmias
    • Infective endocarditis
    • Worsening valve dysfunction leading to decompensated heart failure

Prognosis

  • Prognosis depends on:
    • Severity of the valve disease
    • Underlying cause
    • Development of heart failure
    • Timely medical or surgical treatment
  • Patients with mild disease may remain stable with regular follow-up.
  • Severe symptomatic disease has a poorer prognosis if left untreated but improves with appropriate valve repair or replacement.

Key Points / Clinical Pearls

    • Tricuspid stenosis (TS) is rare and is most commonly caused by rheumatic fever.
    • Tricuspid regurgitation (TR) is more common and is often due to right ventricular dilation or pulmonary hypertension.
    • Both conditions can lead to right-sided heart failure.
    • Gold-standard investigation: Transthoracic echocardiography (TTE).
    • TS murmur: Delayed diastolic murmur.
    • TR murmur: Holosystolic murmur that increases with inspiration (Carvallo sign).
    • Treat the underlying cause, manage heart failure symptoms, and consider valve repair or replacement for severe symptomatic disease.