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Tricuspid Stenosis


Guy P. Armstrong

, MD, Waitemata District Health Board and Waitemata Cardiology, Auckland

Reviewed/Revised Nov 2023

Tricuspid stenosis (TS) is narrowing of the tricuspid orifice that obstructs blood flow from the right atrium to the right ventricle. Almost all cases result from rheumatic fever. Symptoms include a fluttering discomfort in the neck, fatigue, cold skin, and right upper quadrant abdominal discomfort. Jugular pulsations are prominent, and a presystolic murmur is often heard at the left sternal edge in the fourth intercostal space and is increased during inspiration. Diagnosis is by echocardiography. TS is usually benign, requiring no specific treatment, but symptomatic patients may benefit from surgery.

The right atrium becomes hypertrophied and distended, and sequelae of right heart disease–induced heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more Heart Failure (HF) develop but without right ventricular (RV) dysfunction; the RV remains underfilled and small. Uncommonly, atrial fibrillation occurs.

Symptoms and Signs of Tricuspid Stenosis

The only symptoms of severe tricuspid stenosis are fluttering discomfort in the neck (due to giant a waves in the jugular pulse), fatigue and cold skin (due to low cardiac output), and right upper quadrant abdominal discomfort (due to an enlarged liver). Patients with mild tricuspid stenosis have no symptoms.

The primary visible sign is a giant flickering a wave with gradual y descent in the jugular veins. Jugular venous distention may occur, increasing with inspiration (Kussmaul sign). The face may become dusky and scalp veins may dilate when the patient is recumbent (suffusion sign). Hepatic congestion and peripheral edema may occur.


  • Soft opening snap

  • Mid-diastolic rumble with presystolic accentuation

On auscultation, tricuspid stenosis is often inaudible but may produce a soft opening snap and a mid-diastolic rumble with presystolic accentuation. The murmur becomes louder and longer with maneuvers that increase venous return (exercise, inspiration, leg-raising, Müller maneuver) and softer and shorter with maneuvers that decrease venous return (standing, Valsalva maneuver).

Diagnosis of Tricuspid Stenosis

  • Echocardiography

Diagnosis of tricuspid stenosis is suspected based on history and physical examination and confirmed by Doppler echocardiography Echocardiography This photo shows a patient having echocardiography. This image shows all 4 cardiac chambers and the tricuspid and mitral valves. Echocardiography uses ultrasound waves to produce an image of... read more Echocardiography showing a pressure gradient across the tricuspid valve. Two-dimensional echocardiography shows thickened leaflets with reduced movement and right atrial (RA) enlargement.

Severe tricuspid stenosis is characterized by

  • Mean forward gradient across the valve > 5 mm Hg

Cardiac catheterization Cardiac Catheterization Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries and veins. Cardiac catheterization... read more Cardiac Catheterization is rarely indicated for evaluation of tricuspid stenosis. When catheterization is indicated (eg, to evaluate coronary anatomy), findings include elevated RA pressure with a slow fall in early diastole and a diastolic pressure gradient across the tricuspid valve.

Treatment of Tricuspid Stenosis

  • Diuretics and aldosterone antagonists

  • Rarely valve repair or replacement

Evidence to guide treatment of tricuspid stenosis is scarce. Patients with symptoms who are not undergoing valve replacement or repair should receive a low-salt diet, diuretics, and aldosterone antagonists.

Patients with severe tricuspid stenosis should undergo intervention if they are symptomatic or if cardiac surgery is being done for other reasons.

Percutaneous balloon tricuspid commissurotomy might be considered for severe TS in patients who cannot undergo surgical repair but only if there is no accompanying tricuspid regurgitation.

Key Points

  • Tricuspid stenosis is almost always due to rheumatic fever; tricuspid regurgitation and mitral stenosis are often also present.

  • Heart sounds include a soft opening snap and a mid-diastolic rumble with presystolic accentuation; the murmur becomes louder and longer with maneuvers that increase venous return (eg, exercise, inspiration, leg-raising) and softer and shorter with maneuvers that decrease venous return (standing, Valsalva maneuver).

  • Treatment includes diuretics and aldosterone antagonists; surgical repair or replacement is rarely needed.

NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
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