MioAtlas
G2: Right-sided valves

Rheumatic tricuspid stenosis

Tricuspid valve stenosis secondary to chronic rheumatic involvement, characterized by fibrous leaflet thickening, commissural fusion, and chordal shortening restricting diastolic opening excursion of the tricuspid valve.

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Definition

Tricuspid valve stenosis secondary to chronic rheumatic involvement, characterized by fibrous leaflet thickening, commissural fusion, and chordal shortening restricting diastolic opening excursion of the tricuspid valve, creating mechanical obstruction to forward flow and a pathological diastolic gradient between right atrium and right ventricle [V1] [V2] [G1-01] [G1-04].

Severity criteria

  • Mild (L): Mean transtricuspid valve gradient < 3 mmHg; Tricuspid valve area (TVA) > 1.5 cm²; Pressure half-time (PHT) < 120 ms [G1-01] [V1].
  • Moderate (M): Mean gradient 3.0–4.9 mmHg; TVA 1.0–1.5 cm²; PHT 120–189 ms [G1-01] [V1].
  • Severe (G): Mean transvalvular gradient ≥ 5 mmHg (at normal heart rate); TVA ≤ 1.0 cm²; PHT ≥ 190 ms; Velocity-time integral (VTI) of transtricuspid flow > 60 cm [G1-01] [V1] [V2].

Findings by layer

Hemodynamics

  • Elevated mean diastolic transtricuspid gradient (mean transtricuspid gradient: L < 3, M 3–5, G ≥ 5 mmHg) [G1-01] [V1].
  • Markedly elevated mean right atrial pressure (G: ≥ 10–15 mmHg) with normal or reduced right ventricular pressures [G1-01].

Rhythm

  • Normal sinus rhythm or atrial fibrillation frequent as a consequence of chronic right atrial stretch and frequent coexistence with rheumatic mitral valve disease [V1] [G1-04].

ECG

  • In sinus rhythm: Tall and peaked P wave (P pulmonale, P > 2.5 mm in leads II, III, and aVF) reflecting severe right atrial enlargement without widening [E1].
  • In advanced stages: Atrial fibrillation [V1].

Heart sounds and murmurs

  • Diastolic rumble: Low-pitched mid-diastolic rumble with presystolic accentuation (in sinus rhythm) auscultated at the 4th–5th left intercostal space at the lower left sternal border (LLSB), increasing in intensity with inspiration [G1-15] [B1].
  • Tricuspid opening snap: High-frequency opening snap auscultated at the left sternal border, earlier than the mitral snap, moving earlier and becoming louder during inspiration [G1-15].
  • First heart sound (S1): Accentuated and loud in the tricuspid area [G1-10].

Arterial pulse

  • Carotid pulse normal or decreased (parvus) due to reduced forward cardiac output in isolated severe stenosis [B4].

Jugular venous pulse

  • Giant 'a' wave (giant a wave) very prominent in sinus rhythm, generated by forceful right atrial contraction against the obstructed stenotic valve [B3].
  • Strikingly slow and flattened 'y' descent (slow y descent) due to delayed diastolic right atrial emptying [B3].

Maneuvers

  • Deep inspiration: Evident increase in loudness of the diastolic rumble and earlier tricuspid opening snap due to inspiratory increase in venous flow crossing the valve [B1] [G1-15].
  • Valsalva maneuver: Murmur intensity decreases during strain phase with immediate recovery on the first post-release beat [B1].

Simulator severity grades

Simulator severity grades: Mild, Moderate, Severe
Baseline rhythm: Normal Sinus Rhythm

Also known as: Rheumatic tricuspid stenosis · Tricuspid valve stenosis · Tricuspid stenosis · Rheumatic tricuspid disease · TS

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [G1-01] Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2008.11.029 PubMed: 19130998
  6. [G1-04] Acute rheumatic fever and rheumatic heart disease . Nat Rev Dis Primers (2016) . DOI: 10.1038/nrdp.2015.84 PubMed: 27188830
  7. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  8. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  9. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  10. [V2] 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation (2020) . DOI: 10.1161/CIR.0000000000000923 PubMed: 33332150