Skip to Main Content

++

  • Much as the mitral valve (MV) and aortic valve (AV) direct blood flow into the systemic circulation, the tricuspid valve (TV) and the pulmonic valve (PV) direct flow into the pulmonary circulation. A functioning right ventricle (RV) is critical to effective loading of the left ventricle (LV). Perioperative RV failure can be quite challenging for the anesthesiologist as it often occurs in the setting of pulmonary artery hypertension, which can be difficult to treat.

++

The TV can develop both stenotic and regurgitant lesions. Tricuspid stenosis (TS) is most often secondary to rheumatic heart disease. Less encountered causes are carcinoid and endomyocardial fibrosis. Obstructing cardiac masses can also occlude the TV.1

++

Tricuspid regurgitation (TR) occurs secondary to pathologic processes affecting the valve itself or as a consequence of RV dilatation. RV dilatation may occur in the setting of pressure or volume overload. Increased RV systolic pressure develops when the RV must work against an increased resistance. This can occur in clinical situations, which increase pulmonary artery (PA) pressure such as mitral stenosis, severe mitral regurgitation, severe left ventricular dysfunction, pulmonary embolism, primary pulmonary hypertension, or lung disease.

++

Endocarditis, connective tissue diseases, carcinoid syndrome, anorectic drugs (fenfluramine), Ebstein abnormality (an apically positioned tricuspid valve), pergolide, and chest radiation therapy can likewise result in TR. Ebstein anomaly is due to apical displacement of the tricuspid valve leaflets especially the septal leaflet associated with TR and RV dysfunction.

++

Patients with TS frequently present with other valvular diseases associated with rheumatic heart disease (eg, mitral stenosis, aortic stenosis). Consequently, their clinical features often represent the impact of these lesions. Long before the patient presents for surgery, echocardiography will have diagnosed any associated lesions.

++

The patient with TR secondary to pulmonary hypertension is likely to present with signs of right heart failure and systemic venous engorgement. Peripheral edema, hepatic dysfunction, and ascites frequently occur. Systolic pulmonary pressures greater than 55 mm Hg1 will readily produce TR even with normal valve structure. Transvenous pacemaker wires or catheters can both cause a mild degree of TR as well. Additionally, many patients have echocardiographically detected TR without clinical significance.

++

The right ventricle and the interaction between the right and left heart are critical to maintaining healthy cardiovascular function. Although patients can survive with only a single ventricle devoted to the systemic circulation (eg, Fontan circulation—Chapter 12), a functioning right heart effectively loads the LV so that the stroke volume (SV) is ejected systemically. When the RV fails, the LV may be inadequately loaded reducing SV.

++

RV failure can develop both acutely and chronically. Acute RV failure can be seen associated with sudden increases in pulmonary vascular resistance (eg, during a protamine reaction) or secondary to myocardial ischemia and infarction. Chronic RV failure presents secondary to progressive increases in pulmonary hypertension (eg, from mitral stenosis, lung diseases, etc) or volume overload ...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.