Tricuspid Valvular Disease

Tricuspid Valvular Disease is a disease of the heart, namely the tricuspid valve between the right ventricle and right atrium.

These valvular lesions are rare, particularly in isolation.

Tricuspid stenosis (TS) is usually due to rheumatic fever and is usually seen in association with left heart valve disease. TS is also sometimes associated with carcinoid syndrome. Tricuspid regurgitation (TR) is usually secondary to right ventricular dilatation as in pulmonary vascular disease. Primary TR is less common and usually caused by rheumatic heart disease or infective endocarditis (heart valve infection).

TS: Causes a reduction in cardiac output that is compensated for by right atrial hypertrophy. Eventually, the back pressure causes a syndrome of right heart failure. TR: causes a volume over load of the right heart with dilatation of the right atrium. Right heart failure ensues. Atrial arrhythmias, particularly atrial fibrillation are common due to the dilatation of the right atrium.

Chest x-ray may show an atrial bulge in either condition. An ECG may show evidence of right atrial hypertrophy with tall peaked p-waves.

The prognosis of tricuspid valve disorders is good. Right heart failure should be treated with standard measures. Surgical replacement of the valves may be necessary to improve symptoms and prevent irreversible cardiac changes that arise which long term cardiac dysfunction.

Medical treatment of complications such as right heart failure (diuretics, salt restrictions). Surgical options such as valve replacements are sometimes necessary for more severe disease.

Hurst's The Heart 8th Edition, McGRAW-HILL 1994. Kumar and Clark Clinical Medicine 4th Edition, W.B SAUNDERS 1998.

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Rheumatic Fever Rheumatic Heart Disease

Rheumatic fever is an inflammatory disease which may develop after an infection with streptococcus bacteria (such as strep throat or scarlet fever) and can involve the heart (especially the valves), joints, skin, and brain.

Rare in developed countries such as the UK, the US and Australia. Incidence has declined from 10% of children in the 1920's to 0.01% of children today. This drop in incidence reflects advances in infection control and treatment of streptococcal infections with antimicrobials. The disease is still common in developing nations such as the Middle and Far East and South America.

Rheumatic fever is preceded by a throat infection with group A streptococcus organsisms.

Following a group A streptococcus pharyngeal infection, usually in childhood (5-15yo) is followed by a systemic syndrome thought to be caused by an autoimmune response triggered by the infection. The systemic syndrome includes:1) Polyarthritis (multiple join pain and inflammation)2) Carditis (heart inflammation) 3) Skin manifestations 4) Nervous system manifestations5) Fever, joints pains etc.About 50% of patients who develop carditis during the initial phase of the illness will go on to develop long term rheumatic heart disease and associated valvular heart disease.

1) Blood tests: ESR and CRP (non-specific markers of inflammation), leukocytosis2) Chest x-ray: may show evidence of carditis, pericarditis, pericardial effusion.3) ECG: may show evidence of carditis (prolonged P-R interval) or of pericarditis (saddle shaped ST segment elevations).

Some parts of the acute clinical syndrome may recur after the intial episode. However the prognosis for the joint disease, skin disease and nervous system disease associated with rheumatic fever is excellent with no known long term sequelae. Rheumatic heart disease has traditionally been hailed the major causative factor in valvular heart disease and carries the associated morbidity and mortality.

Residual strep infection should be treated with a single intramuscular dose of 916mg of benzylpenicillin. Rest is important. The acute syndrome is treated with high dose aspirin therapy to the limit of tolerance as judged by the development of tinnitus. If carditis is present, steroid therapy may play a role in reducing progression to chronic rheumatic heart disease. Subsequent strep infections should be treated promptly.

[1] Hurst's The Heart 8th Edition, McGRAW-HILL 1994.[2] Kumar and Clark Clinical Medicine 4th Edition, W.B SAUNDERS 1998.[3] MEDLINE Plus.

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