Pulmonary Artery Banding: Background, History of the Procedure, Pathophysiology



tricuspid valve and pulmonary valve :: Article Creator

Tricuspid Valve Regurgitation

Introduction

Tricuspid valve regurgitation occurs when blood abnormally flows backwards from the right ventricle into the right atrium through a diseased tricuspid valve.

Tricuspid regurgitation can be organic from actual valve or leaflet damage, or functional from tricuspid annular dilation. Even in the setting of severe tricuspid regurgitation, right heart failure may not develop. Historically, tricuspid valve excision was performed to remove bacterial vegetations. This results essentially in "wide-open" tricuspid regurgitation and most patients did clinically well. 

Etiology

Functional tricuspid regurgitation is the most common etiology. This occurs due to any cause of pulmonary hypertension which in turn results in increased right ventricular pressure dilating the tricuspid valve annulus.

Rare causes include pacemaker lead leaflet damage, damage from heart biopsies (heart transplant patients), carcinoid valve disease, tricuspid valve prolapse, rheumatic tricuspid valve disease, endocarditis, connective tissues diseases or radiation therapy.

Symptoms

The symptoms of tricuspid regurgitation include those of right heart failure. Dyspnea on exertion is from reduced right ventricular cardiac output. Peripheral edema and right upper quadrant pain from hepatic congestion can occur.

Physical Examination

The murmur of tricuspid regurgitation is similar to that of mitral regurgitation. It is a high pitched, holosystolic murmur however it is best heard at the left lower sternal border and it radiates to the right lower sternal border.  The intensity significantly increases with inspiration due to increased venous return helping to distinguish it from mitral regurgitation. This inspiratory enhancement of the tricuspid regurgitation murmur is called "Carvallo's sign".

Systolic hepatic pulsations may be felt in the right upper quadrant due to hepatic congestion. Peripheral pitting edema is frequently present. Large jugular V waves (Lancisi's sign) are seen during systole and represent the regurgitant volume. See the large jugular V waves in the video below in a patient with severe tricuspid regurgitation:

Diagnosis

The diagnosis is predominantly made on physical examination and echocardiography. The subjective size of the regurgitant jet is the main determinant on grading the TR as mild, moderate or severe.

Treatment

No specific medical therapy exists for tricuspid regurgitation. Diuretics to maintain a normal volume status can help to relieve dyspnea. Digoxin can increase right ventricular contractility, however has not been extensively researched for this indication.

Surgical repair or replacement is rarely required. The ACC/AHA Guidelines give the following indications to surgically repair the tricuspid valve:

  • Repair of the tricuspid valve in severe tricuspid regurgitation when mitral valve surgery is planned (class I, level of evidence B).
  • Tricuspid valve replacement or annuloplasty ring is reasonable to severe primary tricuspid regurgitation when right heart failure symptoms are present (class IIa, level of evidence C).
  • Tricuspid valve replacement is reasonable for severe tricuspid regurgitation due to organic valve disease that is not amenable to annuloplasty ring (class IIa, level of evidence C).
  • Tricuspid annuloplasty ring may be considered for moderate tricuspid regurgitation in patients undergoing mitral valve surgery when there is pulmonary hypertension or tricuspid annular dilatation (class IIb, level of evidence C).

    • By Steven Lome


    Structure Of The Cardiovascular System

    If you clench your hand into a fist, this is approximately the same size as your heart. It is located in the middle of the chest and slightly towards the left.

    The heart is a large muscular pump and is divided into two halves - the right-hand side and the left-hand side.

    The right-hand side of the heart is responsible for pumping deoxygenated blood to the lungs.

    The left-hand side pumps oxygenated blood around the body.

    Each side of the heart consists of an atrium and a ventricle which are two connected chambers.

    The atria (plural of atrium) are where the blood collects when it enters the heart.

    The ventricles pump the blood out of the heart to the lungs or around the body.

    The septum separates the right-hand and left-hand side of the heart.

    The tricuspid valve separates the right atrium and right ventricle. It opens due to a build-up of pressure in the right atrium, and prevents back flow of blood from the right ventricle to the right atrium.

    The bicuspid valve separates the left atrium and left ventricle and prevents back flow of blood from the ventricle to the atrium. It likewise opens due to a build-up of pressure, this time in the left atrium.

    The semilunar valves stop the back flow of blood into the heart. There is a semilunar valve where the aorta leaves the left ventricle and another where the pulmonary artery leaves the right ventricle.

    Blood vessels leading into and out of the heart

    There are four main blood vessels that take blood into and out of the heart.

    The aorta is the largest artery in the body. It carries oxygenated blood away from the left ventricle to the body.

    The vena cava is the largest vein in the body. It carries deoxygenated blood from the body back to the heart.

    The pulmonary artery carries deoxygenated blood away from the right ventricle to the lungs.

    The pulmonary vein returns oxygenated blood from the lungs to the heart.

    Arteries carry oxygenated blood away from the heart (except for the pulmonary artery which carries deoxygenated blood away from the right ventricle to the lungs).

    The main artery is the aorta.

    The main vein is the vena cava.

    The double-circulatory system

    The heart works as a dual action pump – two pumps that work at the same time to pump blood in two different directions.

    The right-hand side of the heart collects deoxygenated blood from the body and pumps it to the lungs (to collect more oxygen). This is called pulmonary circulation.

    The left-hand side of the heart collects oxygenated blood from the heart and pumps it round the body. This is called systemic circulation.

    The pathway of blood through the heart

    Left-hand side

    Oxygenated blood is carried to the heart from the lungs in the pulmonary vein. It goes into the left atrium, through the bicuspid valve and into the left ventricle. The ventricle pumps the blood through the semilunar valve, into the aorta and round the body.

    Right-hand side

    Deoxygenated blood from the body is carried to the heart in the vena cava. It goes into the right atrium, through the tricuspid valve and into the right ventricle. The ventricle pumps the blood through the semilunar valve, into the pulmonary artery and to the lungs.


    A Stepwise Approach To The Management Of Metastatic Midgut Carcinoid Tumor

    Background. A 48-year-old man presented with diarrhea, flushing, abdominal pain and weight loss of 10 kg over a 6-month period. He subsequently developed dyspnea on exertion.

    Investigations. Physical examination, laboratory tests, CT of the abdomen, liver biopsy, echocardiography, immunohistochemistry staining of the biopsy specimen for neuroendocrine markers including chromogranin A, synaptophysin and protein gene product 9.5, and 111In-pentetreotide scintigraphy (Octreoscan™).

    Diagnosis. Carcinoid tumor of midgut origin with large segment 3 liver metastasis. Carcinoid syndrome and carcinoid heart disease.

    Management. Symptomatic relief with somatostatin analog therapy and subsequent resection of the segment 3 liver metastasis. Tricuspid and pulmonary valve replacement.





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