A prospective study comparing the haemodynamic with the cross-sectional echocardiographic diagnosis of rheumatic tricuspid stenosis

SUMMARY The value of cross-sectional echocardiography in the diagnosis of tricuspid valve stenosis is not clearly established. We prospectively studied by cardiac catheterization 42 consecutive patients, with a mean age of 29 ± 11 years, who exhibited the cross-sectional echocardiographic features of tricuspid valve stenosis, defined as: diastolic doming of all three tricuspid leaflets and leaflet thickening with restrictive motion. To expose occult and amplify borderline tricuspid diastolic gradients, simultaneous right atrial and right ventricular pressures were recorded in the basal state, after incremental infusions of normal saline to 200,400,500, 700 or 1000 ml until a mean right atrial pressure of 12 mmHg was achieved, and finally after intravenous administration of 0.6 mg of atropine. Eighteen patients, Group 1, (43%) exhibited mean tricuspid diastolic gradients >2mmHg after saline infusion, increasing from a mean of4 ± 2 to 9 ± 3 mmHg, (P <0.001), 14 (33%) having gradients <2mmHg in the basal state, together with four (10%) increasing from 1.7 ± 0.2 to 4.5 ± l.2 mmHg (P <0.01) after provocation with fluid challenge. In the remaining 24 patients, Group 2, (57%) the mean tricuspid diastolic gradient was <2 mmHg, both at rest and after provocative manoeuvres. We conclude that the cross-sectional echocardiographic features of tricuspid valve stenosis are not a precise indicator of tricuspid valve stenosis. Provocative manoeuvres during haemodynamic studies are required to expose occult or amplify borderline tricuspid diastolic gradients in a minority of patients with the cross-sectional echocardiographic features of tricuspid stenosis.