AbstractTricuspid valve stenosis is mostly rheumatic in origin. It almost always occurs in association with mitral valve disease. There are only few case reports of isolated tricuspid valve stenosis. We report a case of isolated tricuspid valve stenosis, which was treated with balloon dilatation

Bhardwaj, Rajeev

Sharma, Rajesh

Indian Heart Journal

PubMed

Tricuspid valve stenosis is mostly rheumatic in origin. It almost always occurs in association with mitral valve disease. There are only few case reports of isolated tricuspid valve stenosis. We report a case of isolated tricuspid valve stenosis, which was treated with balloon dilatation

Rajeev Bhardwaj

Rajesh Sharma

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Balloon dilatation of isolated severe tricuspid valve stenosis

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Balloon dilatation of isolated severe tricuspid valve stenosis 

Case ReportBalloon dilatation of isolated severe tricuspid valvestenosisRajeev Bhardwaj a,*, Rajesh Sharma baProfessor, Department of Cardiology, Indira Gandhi Medical College, Shimla, IndiabSenior Resident, Department of Cardiology, Indira Gandhi Medical College, Shimla, Indiai n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 7 8 – s 8 0a r t i c l e i n f oArticle history:Received 10 June 2015Accepted 11 September 2015Available online 18 December 2015Keywords:Rheumatic heart diseaseMitral stenosisTricuspid stenosisa b s t r a c tTricuspid valve stenosis is mostly rheumatic in origin. It almost always occurs in associationwith mitral valve disease. There are only few case reports of isolated tricuspid valve stenosis.We report a case of isolated tricuspid valve stenosis, which was treated with balloondilatation.# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.Available online at www.sciencedirect.comScienceDirectjournal homepage: www.elsevier.com/locate/ihj1. IntroductionRheumatic heart disease (RHD) is still a common cause of heartdisease in India. Most common valve involved in RHD is mitralvalve, followed by aortic valve. Tricuspid valve (TV), wheninvolved, is almost always associated with mitral valvedisease.2. CaseA 25-year-old female presented with periorbital pufﬁness andeasy fatigability for the past two years. She developed swellingover both the lower limbs for the past two weeks. Onexamination, her vital signs were stable. The jugular venouspressure (JVP) was found to be raised, 8 cm above the sternalangle, with prominent A wave and slow Y descent. The apex* Corresponding author.E-mail address: rajeevbhardwaj_dr@yahoo.com (R. Bhardwaj).http://dx.doi.org/10.1016/j.ihj.2015.09.0200019-4832/# 2015 Cardiological Society of India. Published by Elseviebeat was in the 5th intercostal space, medial to mid clavicularline. The intensity of the ﬁrst heart sound was loud and 2ndheart sound was normal. There was mid diastolic murmur,medial to apex, with presystolic accentuation, which in-creased on inspiration. There was no other murmur. Liver wasenlarged 5 cm below costal margin with prominent diastolicpulsations.ECG showed right atrial (RA) enlargement.X-ray chest showed cardiomegaly with RA enlargementand a prominent superior vena caval shadow.Echocardiography showed normal mitral, aortic, andpulmonary valves. TV was thickened and doming along withthickened and fused chordae (Fig. 1). The peak gradient acrossTV was 15 mm Hg and mean gradient was 12 mm Hg. RA wasdilated, but RV was small. The diameters of tricuspid annulusand pulmonary annulus were 32 mm and 16 mm, respectively.There was no atrial septal defect or patent foramen ovale.Oxygen saturation of the patient was 95%.r B.V. All rights reserved.Fig. 1 – Echocardiography in 4 chamber view showingthickened and doming tricuspid valve with normal mitralvalve.Fig. 2 – Guide wire passed across TV, PV into PA.Fig. 3 – Balloon dilatation with 7 mm T 40 mm balloon.i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 7 8 – s 8 0 S79So the ﬁnal diagnosis was isolated tricuspid valve stenosis(TS).Uncommon causes of isolated TS were excluded by variousinvestigations,1 and possibility of rheumatic origin was kept.Since the tricuspid annulus and its leaﬂets were of normal sizeand the patient presented at 23 years of age, the possibility ofcongenital origin was very low.Some of the special investigations done were:5 Hydroxyindole acetic acid (5-HIAA) in urine: 1.19 mg/gcreatinine (normal < 10.00)Antiphospholipids antibody, IgM: 2.54 MPL/ml (nor-mal < 10.00)Lupus anticoagulant: absentThe patient was taken up for balloon dilatation of TVthrough right femoral venous approach and Inoue balloon wasplaced in RA. But even after struggling for around two hours,we could not negotiate the balloon across TV. So at this stagethe procedure was abandoned. The patient was again taken upfor balloon tricuspid valvotomy (BTV) after one month. Thistime, with the help of multipurpose catheter, 0.018 in. guidewire was negotiated across the TV into RV. But as soon theeffort was made to push the catheter into the RV, wire cameback into the RA. This happened every time while attemptingto push any catheter across the TV. Subsequently, with greatdifﬁculty, the wire was negotiated into pulmonary artery(Fig. 2). We then tried to pass 23 mm  40 mm balloon acrossthe tricuspid valve, but the stenosis was so severe that wecould not cross this balloon. So we crossed 7 mm  40 mmballoon and dilated the TV with this (Fig. 3). Now we could pass23 mm  40 mm balloon and inﬂated it across TV (Fig. 4).Subsequently we passed another 0.018 in. guide wire across TVinto the pulmonary artery and did double balloon dilatationwith 23 mm  40 mm and 17 mm  40 mm balloons (Fig. 5).The mean gradient across TV decreased from 12 mm Hg to4 mm Hg.The patient had marked improvement in symptoms andwas discharged on third day after the procedure.Table 1 shows the hemodynamic data of the patient beforeand after balloon dilatation.3. DiscussionIsolated TS is a rare condition. TS is mostly rheumatic in originand in that case, almost always associated with mitral valvedisease. Congenital TS is very rare and presents early in life.There are very few case reports of isolated TS of rheumaticetiology in literature.1,2 Morgan et al. did ﬁrst surgicalcommissurotomy of isolated TS of rheumatic etiology.2 BeforeTable 1 – Pressure data on cardiac catheterization (in mmof Hg).Predilatation PostdilatationFemoral artery pressure 140/98/117 136/94/114Right atrium pressure(mean)25 16Right ventricle enddiastolic pressure9 14Mean gradient acrosstricuspid valve12 4Pulmonary arterypressure15/8/13 18/10/15Fig. 4 – Balloon dilatation with 23 mm T 40 mm balloon.Fig. 5 – Balloon dilatation with two balloons(23 mm T 40 mm and 17 mm T 40 mm).i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 7 8 – s 8 0S80this, all three cases of isolated TS, who underwent surgicalcommissurotomy, had TS of congenital origin.3 All of thesecases had subsequent clinical improvement. Longest follow-up was of 14 months, and this patient had persistent gradientacross TV. Jaibag et al. reported the ﬁrst percutaneoustreatment of isolated TS of rheumatic origin by double balloontechnique.4 They did valvotomy by keeping two wires acrossTV, in the right ventricle. Lokhandwala et al. performed theﬁrst successful valvotomy of congenital TV stenosis.5 Theyalso did it with two balloons placed between RA and RV. Wehave also reported a case of isolated tricuspid stenosis.6 Thiswas the same case we took for balloon valvotomy. Since the RVwas small and TV was very narrow, we could not keep theballoon in RV. We had to take the wire into pulmonary arteryand required to do dilatation with smaller balloon, then withlarger balloon and ﬁnally with two balloons.Since isolated TS is a very rare entity, with only few casereports of balloon dilatation, there are no guidelines of whatballoon size is to be used. Whether jugular approach will bemore suitable for crossing the tight stenosis of tricuspid valveis also not clear but may be tried if femoral approach isunsuccessful.4. ConclusionIsolated tricuspid valve stenosis is very rare and is mostlycongenital in origin. Most of the cases have been treatedsurgically. Our report shows that percutaneous treatment,though difﬁcult, is a good alternative.Conﬂicts of interestThe authors have none to declare.r e f e r e n c e s1. Bahaa M, Fadel BM, Hiatt BL, Kerins DM. Isolated rheumatictricuspid stenosis with reverse Lutembacher's physiology.Echocardiography. 2007;16:567–573.2. Morgan JR, Forker AD, Coates JR, Mayer WS. Isolated tricuspidvalve stenosis. Circulation. 1971;44:729–732.3. Killip T, Lukas D. Tricuspid stenosis, clinical features in 12cases. Am J Med. 1958;24:836.4. Jaibag MA, Ribeiro P, Kasab SA. Percutaneous balloonvalvotomy in tricuspid stenosis. Br Heart J. 1987;57:51–53.5. Lokhandwala YY, Rajani RM, Dalvi BV, Kale PA. Successfulballoon valvotomy in isolated congenital tricuspid stenosis.Cardiovasc Intervent Radiol. 1990;13:354–356.6. Bhardwaj R. Isolated tricuspid valve stenosis-probably ofrheumatic etiology. J Assoc Phys India. 2014;62:641–643.

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Balloon dilatation of isolated severe tricuspid valve stenosis

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