Echo Diagnosis of Rheumatic Tricuspid Valve Disease

Rheumatic tricuspid valve disease (RTVd) remains uncommon. When present, it is almost always associated with rheumatic mitral valve disease (RMVd). Previously reported to occur in 2–22% of patients with RMVd, it appears to be less common today. A reported incidence of RTVd in patients with RMVd was 9.5% (14 of 147) in 1984, from a North American medical center. It now appears to be less common. The third world and especially the Indian subcontinent still have a significant prevalence of RTVd, occurring mostly in young women. The clinical findings associated with RMVd are more severe than that of RTVd, making it rather easy to miss the diagnosis of concomitant tricuspid stenosis (TS). It is important to detect tricuspid valve disease, however, as TS may lead to chronic elevation of right atrial pressures, low cardiac output, and venous congestion after surgical or balloon therapy of mitral stenosis (MS). A markedly dilated right atrium serves as a clue to possible TS. An increase in valve brightness and thickness results from fibrosis, causing deformed tricuspid leaflets, mostly along the free edges of the valve. Calcification is rare. As occurs with the mitral valve, commissural fusion and diastolic doming occurs secondary to the rheumatic process, with resultant restricted motion. Valve doming may be well seen in a modified parasternal long-axis or apical view. M-mode may reveal a diminished EF slope with diastolic posterior leaflet anterior motion, similar to that noted in MS. (Figs. 1–3, movie clip S1). Doppler gradients of TS are lower than that of MS. The gradient may be as low as 2 mmHg but rise to 5 mmHg after saline infusion (Fig. 4). Usually RTVd is associated with not only TS and echo valve doming but significant tricuspid