1⃣ Anatomy
2⃣ Etiologies
3⃣ Classification
4⃣ Diagnosis
5⃣ Treatment
Resources: @ASE360 @JACCJournals @CircAHA @ACCCardioEd @UMNews @Medtronic
1/10
cc: @dr_chirumamilla
3 leaflets ⬇️ + fibrous annulus + 2 papillary 💪🏽 + chordae tendinae + RA/RV ❤️
⬛️ Anterior 🍃 (largest)
◾️Posterior
▪️Septal (smallest)
(note: throughout #tweetorial, see image descriptions for more content)
![TV is largest and most apically displaced valve (normal TV area is between 7 and 9 cm^2). Tricuspid annulus = complex nonplanar 3D structure w/low posteroseptal portion (towards the RV apex) & high anterolateral portion.](https://pbs.twimg.com/media/DirLB2xW0AANem7.jpg)
![TV has 2 distinct pap muscles (ant & post) + 3rd variable septal pap muscle. Largest pap = typically anterior w/chordae supporting ant & post leaflets. Posterior pap supports post + septal leaflets. Septal pap is variable: absent in up to 20% of normal patients or small, or multiple.](https://pbs.twimg.com/media/DirLHtXX4AAQbOl.jpg)
![Note attachments of leaflets/chordae to papillary muscles, RV free wall, moderator band.](https://pbs.twimg.com/media/DirLL4kXkAAi_qA.jpg)
![](https://pbs.twimg.com/media/DirLPs1XkAA2fQW.jpg)
Keep chart ⬇️ DDx in mind when reading #EchoFirst
~80% of significant TR = FTR/2º to TA dilatation + leaflet tethering ⬅️ RV remodeling ⬅️ volume and/or pressure overload
Structural (1º) cause = less common
![](https://pbs.twimg.com/media/DirM2YvXUAEgc9s.jpg)
![](https://pbs.twimg.com/media/DirM9n2XkAAmJ73.jpg)
Exam 🧐:
✅ Elevated “c-V” waves in JVP
✅ Systolic murmur at LSB that ⬆️ w/inspiration
✅ Pulsatile liver edge, hepatomegaly, ascites
🚨 Murmur can be absent even in advanced TR!
Sx 😷: fatigue, abd fullness, edema, palps (if +AF)
⬇️ from @NEJM
2014 @ACCinTouch @AHAScience Valve Guidelines: bit.ly/2uQkv7P
🔹Stage A = risk of TR
🔹Stage B = progressive TR
🔹Stage C = asymptomatic severe TR
🔹Stage D = symptomatic severe TR
Severe isolated TR a/w excess mortality & morbidity
![](https://pbs.twimg.com/media/DirN-MkXsAEHrOQ.jpg)
![](https://pbs.twimg.com/media/DirOAASWsAE-hAN.jpg)
![](https://pbs.twimg.com/media/DirOBYUWkAAzFL-.jpg)
![](https://pbs.twimg.com/media/DirOC3SXUAAuD-P.jpg)
CXR & ECG ➡️ RV/RV dilation
Dx standard = #EchoFirst for
🔸TR severity/etiology
🔸Chamber size & fxn (#whyCMR can help here, too)
🔸IVC
🔸RVSP/PASP
🔸Hepatic venous flow
🔸Left ❤️ disease
![](https://pbs.twimg.com/media/DirOve-XkAABtgs.jpg)
![](https://pbs.twimg.com/media/DirOxRVXsAAAV3G.jpg)
![](https://pbs.twimg.com/media/DirOynjWAAAhdRV.jpg)
![](https://pbs.twimg.com/media/DirOzuPXsAEX-jX.jpg)
Be mindful 🤔 of your imaging view/modality limitations!
Characterizing TR severity needs *integrative* assessment of multiple qualitative+quantitative parameters
Great read: @ASE360 Guidelines for Right Heart Echo Assessment: bit.ly/2O4u7Vb
![](https://pbs.twimg.com/media/DirPWZhXsAE0oBU.jpg)
![](https://pbs.twimg.com/media/DirPYX2XUAA7AdS.jpg)
![](https://pbs.twimg.com/media/DirPa0GX0AEsoN-.jpg)
![](https://pbs.twimg.com/media/DirPet4WAAA-N12.jpg)
Stage D:
◽️Diuretics can be useful
◽️Loop diuretics typical
🚨 Aggressive diuresis can ⬇️ LVSV and CO
Stages C/D, severe FTR:
◾️Consider other medical therapies to down arrow PASP and/or PVR
◾️Specific pulmonary vasodilators may help in #cvPH
![](https://pbs.twimg.com/media/DirP7RxXkAEXlQ8.jpg)
Tons of great reads out there-in addition to those in tweets:
@JACC 2015 bit.ly/2Ls4K1k
@Circ 2016 bit.ly/2A0l6cX
@Lancet 2016 bit.ly/2Lwca3m
@ESC 2017 bit.ly/2uU4PR0
![](https://pbs.twimg.com/media/DirRZVAXUAAeooL.jpg)