Tricuspid stenosis: a narrowed heart valve, its causes, symptoms and treatment

The heart has four valves that keep blood flowing in one direction. The British Heart Foundation compares them to a one-way traffic system, with small flaps (leaflets or cusps) that open and close with every heartbeat. The tricuspid valve lies between the right atrium and the right ventricle, the two chambers on the right side of the heart.

Heart Valve Voice, a UK charity, explains that tricuspid valve disease occurs when this valve is restricted, which is stenosis, or leaks backwards, which is regurgitation. The NHS says that when a valve does not open fully the heart has to work harder to pump blood around the body. In tricuspid stenosis the opening narrows and obstructs blood moving from the right atrium to the right ventricle.

A UK clinical reference explains the consequences: the right atrium becomes enlarged and heart failure on the right side can develop, while the right ventricle stays underfilled and small. This is why liver congestion, fluid in the abdomen and swelling feature among the symptoms below.

The clinical reference sets out three groups of causes. Acquired causes are by far the most common, and the leading one is rheumatic heart disease, which is almost always associated with mitral stenosis. Rare causes include large infected vegetations on the valve, carcinoid syndrome, systemic conditions such as systemic lupus erythematosus and antiphospholipid syndrome, hypereosinophilic syndrome, endomyocardial fibrosis, benign tumours such as atrial myxoma, and metastatic disease.

Congenital causes are very rare and usually accompany other heart abnormalities, for example Ebstein anomaly. Iatrogenic causes, meaning those arising from medical care, include pacemaker or defibrillator leads, which can occasionally cause valve stenosis, a rare complication of surgery for tricuspid regurgitation, and appetite suppressant drugs such as fenfluramine. Heart Valve Voice also lists rheumatic fever, endocarditis, pulmonary hypertension and certain medicines as contributors to tricuspid valve disease in general.

The NHS lists causes of heart valve disease overall as being born with the condition, changes in the heart with age, particularly if you smoke or have high blood pressure or high cholesterol, conditions such as rheumatic fever, cardiomyopathy or endocarditis, and damage from a heart attack.

The clinical reference notes that tricuspid stenosis is almost always associated with left-sided valve lesions that dominate the picture, so signs are often masked, especially by mitral stenosis. Some people with heart valve disease have no symptoms at all, and the NHS says it is sometimes found by chance when a doctor hears a heart murmur.

• Fatigue and weakness, from reduced blood output.

• Weight loss and reduced appetite.

• A sensation of a rapid pulse in the neck.

• Discomfort under the right ribs from an enlarged liver, with fluid in the abdomen (ascites) and swollen ankles or legs, which can be out of proportion to breathlessness.

• Palpitations or an irregular heartbeat. The clinical reference says atrial fibrillation is seen in 50% of people with tricuspid stenosis.

• Breathlessness, chest discomfort or dizziness, which the NHS and BHF list for heart valve disease generally.

The NHS advises seeing a GP if you are regularly short of breath, feel tired, weak or dizzy during normal activities, have palpitations that keep coming back, last longer than a few minutes or are getting worse, have swollen ankles or feet, or have chest pain that comes and goes. These symptoms have many causes, but should be checked.

The NHS says to call 999 or go to A&E if you are struggling to breathe, have sudden chest pain that spreads to the arms, back, neck or jaw or lasts more than 15 minutes, or have chest pain with shortness of breath or palpitations. The BHF adds that people with known valve disease should ask for an urgent appointment if symptoms are getting worse, if they have a temperature with no obvious cause, or if they sweat at night or lose weight without a reason.

A GP will listen to your heart and may arrange tests or a referral to a cardiologist, the NHS says. The tests it lists are an echocardiogram (ultrasound scan of the heart), a chest X-ray and an electrocardiogram (ECG). The BHF adds blood tests, cardiac CT, cardiac MRI and an angiogram to the possible tests.

For tricuspid stenosis specifically, the clinical reference says echocardiography is the most useful test for detecting and quantifying the narrowing, measuring the heart chambers and the pressures on the right side and looking for other valve abnormalities. Liver blood tests may be mildly abnormal because of congestion. Cardiac catheterisation may be needed before surgery to assess the coronary arteries and the severity of the stenosis.

Treatment depends on severity and on what else is wrong with the heart. The BHF says mild valve disease with no symptoms may not need treatment and will usually be monitored with check-ups, including an echocardiogram every 3 to 5 years, while moderate or severe disease without symptoms is checked every 6 to 12 months.

The clinical reference says that prognosis is generally good but depends on the underlying disease, other heart abnormalities and rhythm problems. It also states that operative mortality for isolated tricuspid stenosis surgery is significant and rises when other valves are operated on at the same time, which is why decisions are made by a specialist team. The NHS lists possible complications of valve disease as heart failure, atrial fibrillation, stroke and endocarditis.

Heart Valve Voice notes that tissue valves generally need replacing after 10 to 15 years while mechanical valves need lifelong blood-thinning medicine. The BHF encourages healthy lifestyle choices and suggests asking the team about exercise, diet, work, flying, contraception, driving, having children, antibiotics and visiting the dentist. If you are pregnant or planning pregnancy the NHS says to get advice from a heart specialist beforehand.

The usual NHS route is GP, echocardiogram and referral to a cardiology team that includes a specialist valve service, often with a nurse specialist as your point of contact. Private cardiology can offer the same tests, usually with shorter waits to the first appointment. Whichever route you take, make sure you know who will review you at regular intervals and which service to contact if symptoms change.