Tricuspid ValveEdit
The tricuspid valve is a key component of the heart’s right-sided circulation, sitting between the right atrium and the right ventricle. Its primary job is to maintain unidirectional blood flow during the cardiac cycle, opening to allow venous blood to move into the ventricle during diastole and closing during systole to prevent backflow into the atrium. The valve’s structure—three leaflets, a fibrous ring known as the annulus, supporting chordae tendineae and papillary muscles—is designed to coordinate with the heart’s rhythm and pressures, adapting to changes in volume and pressure that occur with everyday activity and disease.
In normal function, the tricuspid valve works in concert with the other heart valves to preserve efficient forward flow and to shield the right atrium and right ventricle from backflow. Its action is tightly linked to the right heart anatomy and the intrathoracic pressures that change with respiration. Because the tricuspid valve is in close proximity to the conduction system, disease or interventions affecting this region can sometimes influence heart rhythm and electrical timing. The valve’s performance can be assessed with imaging and hemodynamic testing, and abnormalities can reflect diseases of the valve itself or problems downstream in the right heart or lungs.
Anatomy and physiology
The tricuspid valve comprises three leaflets—anterior, posterior, and septal—anchored to a fibrous ring called the annulus. The leaflets coapt during systole to prevent regurgitation. The leaflets are tethered by chordae tendineae to the papillary muscles, which contract to keep the leaflets from billowing backward when the right ventricle contracts. The annulus itself is dynamic, changing size with loading conditions and respiration, which can predispose to regurgitation when it dilates. The valve’s location places it at the border of the systemic venous return and the right ventricular outflow, making its function sensitive to right atrial pressure, venous return, and overall heart performance.
In development, the tricuspid valve forms as part of the mature heart’s pattern of endocardial cushions and valvular remodeling. Its leaflets, annulus, and supporting apparatus behave as a unit, and disturbances in any component can lead to valve dysfunction. The surrounding anatomy, including the right atrium and right ventricle, as well as adjacent structures like the inferior vena cava and the coronary sinus, influence the valve’s geometry and function.
Pathology
Disease of the tricuspid valve is relatively common and can arise from primary valve pathology, or more often as a consequence of disease elsewhere in the heart. The two major categories are tricuspid regurgitation (TR) and tricuspid stenosis (TS).
Tricuspid regurgitation (TR) occurs when the leaflets fail to coapt fully, allowing blood to leak back from the right ventricle into the right atrium during systole. TR can be primary (organic disease of the valve itself, such as rheumatic disease, infective endocarditis, endocardial cushion defects, carcinoid disease, or degenerative changes) or secondary/functional (most common), where annular dilation and right ventricular remodeling—often from left-sided heart disease, pulmonary hypertension, or chronic volume overload—impair leaflet coaptation.
Tricuspid stenosis (TS) is less common and typically results from rheumatic disease or other infiltrative processes; it narrows the orifice and impedes flow from the right atrium to the right ventricle. Entities such as carcinoid syndrome can also affect valve mechanics and lead to stenotic lesions.
When TR is significant, the right atrium can enlarge, venous pressures rise, and symptoms of congestion emerge—peripheral edema, ascites, hepatomegaly, and fatigue. In advanced cases, TR contributes to progressive right-sided heart failure and diminished quality of life. Chronic TR can coexist with left-sided valve disease, pulmonary disease, or systemic conditions, complicating management.
Infective endocarditis of the tricuspid valve is classically associated with intravenous drug use, although it can occur in other settings. Carcinoid heart disease can cause plaque-like deposits on the leaflets, leading to stenosis or regurgitation.
Diagnosis and imaging
Diagnosis combines history, examination, and modern imaging. A characteristic finding on examination is a holosystolic murmur best heard at the left lower sternal border, which may radiate and change with respiration and venous pressure. However, many patients, especially with functional TR, have subtle signs until the disease is advanced.
Imaging is central to evaluation. Transthoracic echocardiography provides visualization of leaflet motion, annular size, and the degree of regurgitation or stenosis, while transesophageal echocardiography can offer higher-resolution assessment when needed. Cardiac MRI and CT can complement echo in complex cases or when planning interventions. Hemodynamics may be assessed with right heart catheterization if precise pressure measurements are required to guide therapy or to evaluate coexisting conditions such as pulmonary hypertension.
Specialized imaging and measurements help determine the mechanism of dysfunction—whether the problem is primarily the valve itself or secondary to annular dilation and right ventricular remodeling. The interplay with nearby structures, including the right atrium and inferior vena cava, often shapes both symptoms and treatment options.
Management and treatment
Management is tailored to the underlying cause, the severity of valve dysfunction, and the patient’s overall health and goals. A stepwise approach typically includes medical therapy, followed by surgical or transcatheter interventions when indicated.
Medical management focuses on treating contributing conditions and reducing symptoms. Diuretics can alleviate congestion; therapies for atrial fibrillation or right heart failure may be employed; and management of associated left-sided valve disease or pulmonary hypertension is essential. In some patients, optimizing volume status improves TR-related symptoms even when the valve itself is not repaired.
Surgical intervention aims to correct the valve mechanics and improve hemodynamics. Options include valve repair (valvuloplasty) or replacement with a bioprosthetic or mechanical valve, depending on patient factors, durability considerations, and surgical risk. In the context of left-sided valve surgery, convergence of procedures to address the tricuspid valve may be considered to balance overall outcomes.
Transcatheter therapies have expanded options for patients at high surgical risk. Edge-to-edge repair devices and percutaneous annuloplasty strategies aim to reduce regurgitation by improving leaflet coaptation or reducing the annulus size. Transcatheter tricuspid replacement is an emerging field, with multiple devices under investigation and increasing clinical experience guiding practice. The choice between surgical and transcatheter approaches depends on anatomy, comorbidity, institutional expertise, and patient preferences.
Guidelines and prognosis: Contemporary practice guidelines emphasize a patient-centered approach that weighs symptom burden, valve anatomy, and the presence of concomitant disease. Early intervention in select patients with functional TR—particularly when paired with other valvular procedures—can improve outcomes, though long-term durability and the risk profile of each option remain areas of active study. Health-system factors, access to specialized centers, and comparative effectiveness research influence real-world practice as these therapies evolve.
Epidemiology and history
Tricuspid valve disease ranges from incidental findings to clinically significant pathology. Functional TR, driven by right-sided remodeling and annular dilation, is the most common form in contemporary practice, often evolving alongside left-sided heart disease or pulmonary pathology. The history of treating tricuspid valve disease has evolved from isolated surgical repairs to a spectrum that now includes transcatheter techniques, aligning with broader trends toward less invasive therapy and tailored patient care. The growing emphasis on the right heart in valvular disease reflects a broader shift in cardiology toward comprehensive management of all four valves and the interdependence of cardiac chambers.