Tricuspid and pulmonary valve
Stenosis and regurgitation
Tricuspid stenosis

It is very rare and can be caused by rheumatic heart disease
Clinical presentation
The JVP: raised; giant a waves with a slow y descent may be seen.
Auscultation: a diastolic murmur audible at the left sternal edge, accentuated by inspiration, very similar to the murmur of mitral stenosis except for the site of maximal intensity and the effect of respiration (louder on inspiration); tricuspid regurgitation and mitral stenosis are often present as well; no signs of pulmonary hypertension.
Abdomen: presystolic pulsation of the liver, caused by forceful atrial systole.
Cause of tricuspid stenosis: rheumatic heart disease

Tricuspid regurgitation
Tricuspid regurgitation
The JVP: large v waves; the JVP is elevated if right ventricular failure has occurred.
Palpation: right ventricular heave.
Auscultation: there may be a pansystolic murmur maximal at the lower end of the sternum that increases on inspiration, but the diagnosis can be made on the basis of the peripheral signs alone.
Abdomen: a pulsatile, large and tender liver is usually present and may cause the right nipple to dance in time with the heart beat; ascites, oedema and pleural effusions may also be present.
Legs: dilated, pulsatile veins.
Causes of tricuspid regurgitation:hh (i) functional (no disease of the valve leaflets)-right ventricular failure; (ii) rheumatic-only very rarely does rheumatic tricuspid regurgitation occur alone, usually mitral valve disease is also present; (iii) infective endocarditis (right-sided endocarditis in intravenous drug addicts); (iv) tricuspid valve prolapse; (v) right ventricular papillary muscle infarction; (vi) trauma (usually caused by a steering wheel injury to the sternum): (vii) congenital-Ebstein's anomaly



Pulmonary stenosis
Pulmonary stenosis
General signs: peripheral cyanosis, due to a low cardiac output, but only in severe cases.
Pulse: normal or reduced if cardiac output is low.
The JVP: giant a waves because of right atrial hypertrophy; the JVP may be elevated.
Palpation: right ventricular heave; thrill over the pulmonary area.
Auscultation: the murmur may be preceded by an ejection click; a harsh and usually loud ejection systolic murmur, heard best in the pulmonary area and with inspiration, is typically present; right ventricular S4 may be present (due to right atrial hypertrophy). It is not well heard over the carotid arteries.
Abdomen: presystolic pulsation of the liver may be present.
Signs of severe pulmonary stenosis: an ejection systolic murmur peaking late in systole; absence of an ejection click (also absent when the pulmonary stenosis is infundibular-i.e. below the valve level); presence of S4; signs of right ventricular failure.
Causes of pulmonary stenosis: (i) congenital; (ii) carcinoid syndrome (rare).

Pulmonary regurgitation
is an uncommon pathological condition; trivial pulmonary regurgitation is often found at echocardiography and is considered physiological.
Auscultation: a decrescendo diastolic murmur which is high pitched and audible at the left sternal edge is characteristic-this typically but not always increases on inspiration (unlike the murmur of aortic regurgitation). It is called the Graham Steell murmurjj when it occurs secondary to pulmonary artery dilatation caused by pulmonary hypertension. (Note: If there are no signs of pulmonary hypertension a decrescendo diastolic murmur at the left sternal edge is more likely to be due to aortic regurgitation than to pulmonary regurgitation.)
Causes of pulmonary regurgitation: (i) pulmonary hypertension; (ii) infective endocarditis; (iii) following balloon valvotomy for pulmonary stenosis or surgery for pulmonary atresia; (iv) congenital absence of the pulmonary valve.

TAKEN FROM TALLEY O'CONNOR PG 74 ONWARDS
CHRISTINE