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The tricuspid valve is located between the heart’s right atrium and ventricle. Its role is to make sure blood flows the correct way through the heart, from the right atrium down to the ventricle. The tricuspid valve has three leaflets, or flaps, that control blood flow and direction.
Types of tricuspid disease include:
• Tricuspid regurgitation - the valve is leaky or doesn’t close tight enough.
• Tricuspid stenosis - the valve leaflets are stiff and do not open widely enough, causing a restriction in the forward flow of blood and increased pressure gradient
across the valve, found by echocardiogram or cardiac catheterization.
Tricuspid valve disease can be caused by:
• Infection, such as rheumatic fever or infective endocarditis.
• A dilated right ventricle, causing the annulus (a ring of tough fibrous tissue which is attached to and supports the leaflets of the valve) of the tricuspid valve to enlarge.
• Increased pressure through the tricuspid valve (seen with pulmonary hypertension).
• Less common causes include congenital defects, trauma, carcinoid heart disease, tumor, tricuspid valve prolapse, Ebstein’s anomaly, systemic lupus, and trauma.
In many cases, there are no symptoms. However, if symptoms do occur, they may include:
• Irregular heart rhythm (atrial fibrillation)
• Easily tired (fatigue)
• A fluttering discomfort in the neck
• With severe disease, heart failure symptoms (right abdominal pain, shortness of breath, swelling in the legs or abdomen, cold skin)
Depend on symptoms and medical history. A physical exam will be done. And murmur will be heard, then investigation will be done
• Electrocardiography (ECG)
• Chest X-ray
• Transesophageal echocardiography
• Cardiac Catheterization (cardiac cath or angiogram)
• Radionuclide scans
• Magnetic resonance imaging (MRI)
The surgical indication for Tricuspid valve disease is considered more actively if:
i. Another cardiac operation is considered, whether it is for valve surgery, coronary bypass, or MAZE procedure;
ii. If the pathology is severe, particularly based on quantitative criteria
iii. The patient is symptomatic and there are congestive signs (enlarged pulsatile liver, with pulsatile jugular veins and systolic reversal in the hepatic veins by echo-Doppler). In the absence of congestive signs, marked reduction of functional capacity measured by exercise testing and without other cause than the tricuspid regurge is essential to consider surgery;
iv. The comorbid conditions are not overwhelming and life expectancy is of at least several years.
THE TREATMEANT STATGIES WILL BE:
Nonsurgical Treatment:If mild tricuspid valve disease, medications will be prescribed to treat the symptoms. These medications may include drugs to control heart failure or to manage an irregular heart rhythm. The goal of nonsurgical treatment is to prevent further damage to the heart.
Valve Surgery: If the valve condition is severe or gets worse over time, surgery to repair or replace the diseased valve will be needed. The decision for repair vs. replacement is based on:
o Diagnostic test results (echocardiogram and cardiac catheterization)
o Heart structure and anatomy
o The patient’s age
o The presence of other medical conditions
Tricuspid Valve repair
Is the preferred surgical treatment for tricuspid valve disease. Tricuspid valve repair can be done alone or in combination with treatments for other heart problems. Valve repair is a technically challenging procedure, and the success and outcome depend on the surgeon’s experience and skill, as well as the condition of the patient’s valve. Transesophageal echocardiography can be used during the operation to check the valve’s function before and after surgery.
Advantages of Repair over replacement
• Better survival and outcome statistics
• Better preservation of heart function and anatomy
• Lower risk of complications, such as stroke or endocarditis (infection)
• No need for anticoagulation therapy
• Improved lifestyle
There is several different repair procedures to separate leaflets that have fused, repair leaflets that are torn and reshape parts of the valve, depending on the valve problem.
These techniques include:
Annulus support: involves the use of a tissue-based or synthetic ring to reinforce the annulus, which is the ring of tissue at the base of the valve leaflets. This procedure restores the annulus to right size and shape and allows the leaflets to open and close completely.
Tricuspid valve repair using an annuloplasty ring is the preferred surgical approach for tricuspid regurgitation and may be performed for primary tricuspid disease or for combined cases with other valve surgery (mitral, aortic).
Research has shown that the Rigid prosthetic ring annuloplasty provides better long term outcomes
Leaflet patching is used to treat tricuspid valve regurgitation. The surgeon repairs the torn leaflet with a patch to correct the leaking valve and eliminate blood backflow.
Results of Tricuspid Valve Repair
A cardiovascular surgeon can predict but cannot guarantee the likelihood of a successful tricuspid valve repair. The long-term outcome of a successful repair is most likely to be good, especially for degenerative valve disease. Statistics show up to a 95% chance that a repaired valve will need no further intervention in the next 10 to 20 years (fewer for a more complex repair). However, rheumatic fever can continue to damage a repaired valve, and tricuspid regurgitation associated with coronary artery disease creates unpredictable repair results.
Tricuspid Valve Replacement
Although most patients have their valve repaired, some patients need the valve replaced. Valve replacement may be with either a biologic (tissue-based) or mechanical valve.
Biologic valves are made of pig (porcine), cow (bovine) or human (allograft or homograft) tissue. They last 15 to 20 years and do not require the patient to take anticoagulant (blood-thinning) medication for the rest of their life. At the Miller Family Heart& Vascular Institute, 85 percent of valve replacement procedures in 2010 involved biologic valves.
Mechanical valves are made of metal or carbon surrounded with a polyester knit fabric-covered ring. These valves last longer than biologic valves and require lifelong therapy with blood-thinning medication to reduce the risk of blood clots and stroke.
Minimally Invasive and Robotically Assisted Valve Surgery
Minimally invasive surgery is an option for many patients with tricuspid valve disease. While traditional valve surgery is performed through a 6 – 8 inch incision through the sternum, a minimally invasive approach may include:
• Smaller 3 inch incision through the sternum
• Robotically assisted approach, which involves several small incisions in the chest wall.
• Right thoracotomy approach, which involves a small incision on the right side in between the rib
The benefits of minimally invasive surgery are:
• Smaller incisions with minimal scarring
• Less trauma to the patient, including less pain
• Shorter hospital stay (usually 3 to 4 days)
• Decreased use of pain medications
• Less bleeding
• Decreased risk of infection
• Shorter recovery and quicker return to daily and professional activities: The patient can resume normal activities and work as soon as he or she feels up to it; there are no specific activity restrictions after robotically-assisted surgery.