Health Dictionary

Overview

The differential diagnosis of tricuspid stenosis includes valvular abnormalities causing a similar clinical presentation, and other causes of systemic venous congestion such as constrictive pericarditis.

Differential Diagnosis

The heart murmur of tricuspid stenosis must be differentiated from that of other valvular diseases. However, it should be noted that tricuspid stenosis can coexist with other valvular diseases such as tricuspid regurgitation, mitral valve and aortic valve abnormalities.^[1]
Tricuspid stenosis is characterized by a mid-diastolic murmur best heard over the left sternal border.
It has a rumbling character, a tricuspid opening snap with the wide splitting of S1.
The differential diagnosis of tricuspid stenosis includes:
- Aortic regurgitation: The diastolic murmur of aortic regurgitation decreases with respiration, which is in contrast to that of tricuspid stenosis.
- Mitral regurgitation: The murmur of mitral regurgitation is blowing, soft and best heard at the apex.
- Mitral stenosis: The murmur of mitral stenosis is mid-diastolic, rumbling, and best heard after the opening snap.
- Tricuspid regurgitation: The murmur of tricuspid regurgitation is blowing, holosystolic, and best heard over the fourth intercostal area at the left sternal border.

Tricuspid stenosis must be differentiated from diseases that can cause a similar clinical presentation, such as:

Tricuspid stenosis must be differentiated from the following:^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21]^[22]^[23]^[24]

Diseases	History	Symptoms	Physical Examination	Murmur	Diagnosis				Other Findings
Diseases	History	Symptoms	Physical Examination	Murmur	ECG	CXR	Echocardiogram	Cardiac Catheterization	Other Findings
Mitral Stenosis	Age ( Mitral annular calcification in older patients) Rheumatic fever Endocarditis	Dyspnea on exertion Paroxysmal nocturnal dyspnea Orthopnea New onset atrial fibrillation	Mitral facies Heart murmur Jugular vein distension Apical impulse displaced laterally or not palpable Diastolic thrill at the apex Signs of heart failure in severe cases	Diastolic murmur Low pitched Opening snap followed by a decrescendo-crescendo rumbling murmur Best heard with the bell of the stethoscope at the apex at end-expiration in the left lateral decubitus position Intensity increases after a valsalva maneuver, after exercise and after increased after load (eg., squatting, isometric hand grip)	P mitrale Atrial fibrillation: No P waves and irregularly irregular rhythm Right axis deviation Right ventricular hypertrophy: Dominant R wave in V1 and V2	Straightening of the left border of the heart suggestive of enlargement of the left atrium Double right heart border (Enlarged left atrium and normal right atrium) Prominent left atrial appendage Splaying of subcarinal angle (>120 degrees) Calcification of mitral valve Kerley B lines	Reduced valve leaflet mobility Valve calcification Doming of mitral valve Valve thickening Enlargement of left atrium	Right heart catheterization: Pulmonary capillary wedge pressure (left atrial pressure) Left heart catheterization: Pressures in left ventricle Determines the gradient between the left and right atrium during ventricular diastole (a marker of the severity of mitral stenosis)	Hemoptysis (heart failure) Ortner’s syndrome

Mitral Regurgitation	CAD MI Rheumatic fever Endocarditis Mitral valve prolapse Cardiomyopathy Radiation therapy Trauma	Palpitations Symptoms of heart failure in severe cases	Palpation Brisk carotid upstroke and hyperdymanic carotid impulse on palpation Apical impulse is displaced to left S3 and a palpable thrill Auscultation Murmur	Holosystolic murmur High pitched, blowing Radiates to the axilla Best heard with the diaphragm of the stethoscope at the apex in left lateral decubitus position Intensity increases with hand grip or squatting Decrease in intensity on standing or valsalva maneuver	P mitrale in lead II Increased QRS voltage Right axis deviation Atrial fibrillation	Acute MR Kerley B lines No enlargement of cardiac silhouette Chronic MR Enlarged cardiac silhouette Straightening of left heart border Splaying of subcarinal angle Calcification of mitral annulus Double right heart border	Enlargement of left atrium and ventricle Identify valve abnormality Valve calcification Severity of regurgitation	Grading of MR is done with left ventriculography	Decompensated and acute MR may lead to heart failure

Atrial septal defect	Frequent respiratory or lung infections Dyspnea Tiring when feeding (Infants) Shortness of breath on exertion Palpitations Swelling of feet	Shortness of breath Fatigue Failure to thrive Swelling of feet and abdomen (Right heart failure) Palpitations Respiratory infections	Inspection Precordial bulge Precordial lift Palpation Right ventricular impulse Pulmonary artery pulsations Thrill Auscultation Murmur	Midsystolic (ejection systolic) murmur Widely split, fixed S2 Upper left sternal border	Normal Prolonged PR interval Right bundle branch block ECG findings varies according to the underlying type of ASD	Increased pulmonary markings Cardiomegaly Triangular appearance of heart Schimitar sign	Gold standard test for diagnosis of atrial septal defect (for more information click Atrial septal defect echocardiography)	Defect size Pulmonary venous return Pulmonary vascular resistance Pulmonary artery hypertension	Asymptomatic until later part of their life May be associated with migraine with aura

Left Atrial Myxoma	Dyspnea Orthopnea Pulmonary edema Hyperpigmentation of skin and endocrine activity Cerebral embolism	Symptoms may mimic mitral stenosis	Skin Signs of an embolic phenomenon Raynaud’s phenomenon Swelling Clubbing Auscultation: Lung: Fine crepitations Heart: Characteristic “tumor plop”	Early diastolic sound as “tumor plop” Low frequency diastolic murmur may be heard if the tumor obstructing mitral valve	Often normal	Often normal Rare findings: cardiomegaly Left atrial enlargement tumor calcification etc.,	Initial and most useful diagnostic study For more information click Myxoma echocardiography or ultrasound	Useful to detect vascular supply of the tumor by the coronary arteries	Associated with Carney complex (genetic predisposition)

Prosthetic Valve Obstruction	History of valve replacement Systemic embolism	Shortness of breath Fatigue	Ausculation Muffling of murmur	Muffling or disappearance of prosthetic sounds Appearance of new regurgitant or obstructive murmur			Degree of stenosis Assess thrombus size and location Differentiate between thrombus, pannus and vegetations		Causes: Thrombus Pannus formation

Cor Triatriatum	Dyspnea on exertion Recent onset of congestive heart failure	Dsypnea on exertion Orthopnea Tachypnea Palpitations Growth failure	Auscultation Murmur Other findings Signs of heart failure	Diastolic murmur with loud P2 No opening snap or a loud S1	Non specific but may have Right axis deviation Right atrial enlargement Right ventricular hypertrophy	Normal cardiac silhouette Hemodynamic changes similar to mitral stenosis (non specific findings)	Direct visualization of membrane through the atrium +/- visualization of accessory chamber	Normal left ventricular hemodynamic profile with a trans atrial gradient	Types Cor triatriatum sinistrum Cor triatriatum dextrum

Congenital Mitral Stenosis	Respiratory distress shortly after birth Recurrent severe pulmonary infections Other associated congenital cardiovascular anamolies Atrial fibrillation	Infants: Exhaustion and sweating on feeding Rapid breathing Failure to thrive Pulmonary infections Chronic cough Older patients: Dyspnea Orthopnea Paroxysmal nocturnal dyspnea Peripheral edema Fatigue	Auscultation Murmur Other findings Signs of heart failure	Mild-Moderate Loud S1 Loud P2 Low-frequency diastolic murmur best heard at the apex Severe Soft S1 Loud pulmonic component of S2 with the minimal respiratory splitting of S2 Holodiastolic murmur with presystolic accentuation best heard at the apex Early diastolic murmur of pulmonic valve regurgitation	Sharp P waves in leads I and II Inversion of P wave in lead III Marked Q waves in leads II and III	Left atrial dilation Moderate enlargement of right heart Pulmonary venous congestion Esophageal compression	Reduced valve leaflet mobility Left atrial size Severity of mitral stenosis		Very rare condition

Supravalvular Ring Mitral Stenosis	Other associated congenital heart defects Fatigue Frequent respiratory infections Failure to thrive Poor feeding Precocious congestive heart failure	Shortness of breath Tachypnea Dyspnea Nocturnal cough Heamoptysis Syncope	Auscultation: Lungs: Fine, crepitant rales and rhonchi or wheezes may be present Heart: Murmur	An apical mid diastolic murmur with presystolic accentuation No opening snap The murmur is more prominent if associated with VSD or PDA		Left atrial and ventricular enlargement Alveolar edema	Supramitral ring: Associated with normal mitral valve apparatus Intramitral ring: Hypomobility of the posterior leaflet Reduced interpapillary muscle distance Reduced chordal length Dominant papillary muscle Hypoplastic mitral annulus (Difficult to visualize membrane <1mm in size)	Persistently elevated pulmonary venous pressures Increased pulmonary artery pressure	Types Supramitral Intramitral It is attached between the opening of the atrial appendage and the mitral annulus which helps in differentiating with Cor triatriatum sinister. Intramitral type is associated with shone complex

References

↑ Waller BF, Howard J, Fess S (1995). “Pathology of tricuspid valve stenosis and pure tricuspid regurgitation–Part I.” Clin Cardiol. 18 (2): 97–102. PMID 7720297.
↑ Nassar PN, Hamdan RH (2011). “Cor Triatriatum Sinistrum: Classification and Imaging Modalities”. Eur J Cardiovasc Med. 1 (3): 84–87. doi:10.5083/ejcm.20424884.21. PMC 3286827. PMID 22379596.
↑ Roudaut R, Serri K, Lafitte S (2007). “Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations”. Heart. 93 (1): 137–42. doi:10.1136/hrt.2005.071183. PMC 1861363. PMID 17170355.
↑ Apostolakis EE, Baikoussis NG (2009). “Methods of estimation of mitral valve regurgitation for the cardiac surgeon”. J Cardiothorac Surg. 4: 34. doi:10.1186/1749-8090-4-34. PMC 2723095. PMID 19604402.
↑ Alboliras ET, Edwards WD, Driscoll DJ, Seward JB (1987). “Cor triatriatum dexter: two-dimensional echocardiographic diagnosis”. J Am Coll Cardiol. 9 (2): 334–7. PMID 3805524.
↑ Gibson DG, Honey M, Lennox SC (1974). “Cor triatriatum. Diagnosis by echocardiography”. Br Heart J. 36 (8): 835–8. PMC 458901. PMID 4412638.
↑ Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016
↑ Sosland RP, Vacek JL, Gorton ME (2007). “Congenital mitral stenosis: a rare presentation and novel approach to management”. J Thorac Cardiovasc Surg. 133 (2): 572–3. doi:10.1016/j.jtcvs.2006.10.025. PMID 17258606.
↑ Driscoll DJ, Gutgesell HP, McNamara DG (1978). “Echocardiographic features of congenital mitral stenosis”. Am J Cardiol. 42 (2): 259–66. PMID 685838.
↑ Bonou M, Lampropoulos K, Barbetseas J (2012). “Prosthetic heart valve obstruction: thrombolysis or surgical treatment?”. Eur Heart J Acute Cardiovasc Care. 1 (2): 122–7. doi:10.1177/2048872612451169. PMC 3760527. PMID 24062899.
↑ Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). “Valvular heart disease: diagnosis and management”. Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.
↑ DEXTER L (1956). “Atrial septal defect”. Br Heart J. 18 (2): 209–25. PMC 479579. PMID 13315850.
↑ Webb G, Gatzoulis MA (2006). “Atrial septal defects in the adult: recent progress and overview”. Circulation. 114 (15): 1645–53. doi:10.1161/CIRCULATIONAHA.105.592055. PMID 17030704.
↑ Geva T, Martins JD, Wald RM (2014). “Atrial septal defects”. Lancet. 383 (9932): 1921–32. doi:10.1016/S0140-6736(13)62145-5. PMID 24725467.
↑ Demir M, Akpinar O, Acarturk E (2005). “Atrial myxoma: an unusual cause of myocardial infarction”. Tex Heart Inst J. 32 (3): 445–7. PMC 1336732. PMID 16392241.
↑ MacGowan SW, Sidhu P, Aherne T, Luke D, Wood AE, Neligan MC; et al. (1993). “Atrial myxoma: national incidence, diagnosis and surgical management”. Ir J Med Sci. 162 (6): 223–6. PMID 8407260.
↑ Circulation http://circ.ahajournals.org/content/119/7/1034 (2016) Accessed on December 7, 2016
↑ Alphonso N, Nørgaard MA, Newcomb A, d’Udekem Y, Brizard CP, Cochrane A (2005). “Cor triatriatum: presentation, diagnosis and long-term surgical results”. Ann Thorac Surg. 80 (5): 1666–71. doi:10.1016/j.athoracsur.2005.04.055. PMID 16242436.
↑ circulation http://circ.ahajournals.org/content/36/1/101 (1967) Accessed on 7 December, 2016
↑ Moore P, Adatia I, Spevak PJ, Keane JF, Perry SB, Castaneda AR; et al. (1994). “Severe congenital mitral stenosis in infants”. Circulation. 89 (5): 2099–106. PMID 8181134.
↑ Uva MS, Galletti L, Gayet FL, Piot D, Serraf A, Bruniaux J; et al. (1995). “Surgery for congenital mitral valve disease in the first year of life”. J Thorac Cardiovasc Surg. 109 (1): 164–74, discussion 174-6. doi:10.1016/S0022-5223(95)70432-9. PMID 7815793.
↑ Banerjee A, Kohl T, Silverman NH (1995). “Echocardiographic evaluation of congenital mitral valve anomalies in children”. Am J Cardiol. 76 (17): 1284–91. PMID 7503011.
↑ Sullivan ID, Robinson PJ, de Leval M, Graham TP (1986). “Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease”. J Am Coll Cardiol. 8 (1): 159–64. PMID 3711511.
↑ Subramaniam V, Herle A, Mohammed N, Thahir M (2011). “Ortner’s syndrome: case series and literature review”. Braz J Otorhinolaryngol. 77 (5): 559–62. PMID 22030961.

[pmid7720297-1] Waller BF, Howard J, Fess S (1995). “Pathology of tricuspid valve stenosis and pure tricuspid regurgitation–Part I.” Clin Cardiol. 18 (2): 97–102. PMID 7720297.

[pmid22379596-2] Nassar PN, Hamdan RH (2011). “Cor Triatriatum Sinistrum: Classification and Imaging Modalities”. Eur J Cardiovasc Med. 1 (3): 84–87. doi:10.5083/ejcm.20424884.21. PMC 3286827. PMID 22379596.

[pmid17170355-3] Roudaut R, Serri K, Lafitte S (2007). “Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations”. Heart. 93 (1): 137–42. doi:10.1136/hrt.2005.071183. PMC 1861363. PMID 17170355.

[pmid19604402-4] Apostolakis EE, Baikoussis NG (2009). “Methods of estimation of mitral valve regurgitation for the cardiac surgeon”. J Cardiothorac Surg. 4: 34. doi:10.1186/1749-8090-4-34. PMC 2723095. PMID 19604402.

[pmid3805524-5] Alboliras ET, Edwards WD, Driscoll DJ, Seward JB (1987). “Cor triatriatum dexter: two-dimensional echocardiographic diagnosis”. J Am Coll Cardiol. 9 (2): 334–7. PMID 3805524.

[pmid4412638-6] Gibson DG, Honey M, Lennox SC (1974). “Cor triatriatum. Diagnosis by echocardiography”. Br Heart J. 36 (8): 835–8. PMC 458901. PMID 4412638.

[radiopedia-7] Cor triatrium https://radiopaedia.org/articles/cor-triatriatum (2016) Accessed on November 29, 2016

[pmid17258606-8] Sosland RP, Vacek JL, Gorton ME (2007). “Congenital mitral stenosis: a rare presentation and novel approach to management”. J Thorac Cardiovasc Surg. 133 (2): 572–3. doi:10.1016/j.jtcvs.2006.10.025. PMID 17258606.

[pmid685838-9] Driscoll DJ, Gutgesell HP, McNamara DG (1978). “Echocardiographic features of congenital mitral stenosis”. Am J Cardiol. 42 (2): 259–66. PMID 685838.

[pmid24062899-10] Bonou M, Lampropoulos K, Barbetseas J (2012). “Prosthetic heart valve obstruction: thrombolysis or surgical treatment?”. Eur Heart J Acute Cardiovasc Care. 1 (2): 122–7. doi:10.1177/2048872612451169. PMC 3760527. PMID 24062899.

[pmid20435842-11] Maganti K, Rigolin VH, Sarano ME, Bonow RO (2010). “Valvular heart disease: diagnosis and management”. Mayo Clin Proc. 85 (5): 483–500. doi:10.4065/mcp.2009.0706. PMC 2861980. PMID 20435842.

[pmid13315850-12] DEXTER L (1956). “Atrial septal defect”. Br Heart J. 18 (2): 209–25. PMC 479579. PMID 13315850.

[pmid17030704-13] Webb G, Gatzoulis MA (2006). “Atrial septal defects in the adult: recent progress and overview”. Circulation. 114 (15): 1645–53. doi:10.1161/CIRCULATIONAHA.105.592055. PMID 17030704.

[pmid24725467-14] Geva T, Martins JD, Wald RM (2014). “Atrial septal defects”. Lancet. 383 (9932): 1921–32. doi:10.1016/S0140-6736(13)62145-5. PMID 24725467.

[pmid16392241-15] Demir M, Akpinar O, Acarturk E (2005). “Atrial myxoma: an unusual cause of myocardial infarction”. Tex Heart Inst J. 32 (3): 445–7. PMC 1336732. PMID 16392241.

[pmid8407260-16] MacGowan SW, Sidhu P, Aherne T, Luke D, Wood AE, Neligan MC; et al. (1993). “Atrial myxoma: national incidence, diagnosis and surgical management”. Ir J Med Sci. 162 (6): 223–6. PMID 8407260.

[Obstruction-17] Circulation http://circ.ahajournals.org/content/119/7/1034 (2016) Accessed on December 7, 2016

[pmid16242436-18] Alphonso N, Nørgaard MA, Newcomb A, d’Udekem Y, Brizard CP, Cochrane A (2005). “Cor triatriatum: presentation, diagnosis and long-term surgical results”. Ann Thorac Surg. 80 (5): 1666–71. doi:10.1016/j.athoracsur.2005.04.055. PMID 16242436.

[cortriatriatum-19] rculation http://circ.ahajournals.org/content/36/1/101 (1967) Accessed on 7 December, 2016

[pmid8181134-20] Moore P, Adatia I, Spevak PJ, Keane JF, Perry SB, Castaneda AR; et al. (1994). “Severe congenital mitral stenosis in infants”. Circulation. 89 (5): 2099–106. PMID 8181134.

[pmid7815793-21] Uva MS, Galletti L, Gayet FL, Piot D, Serraf A, Bruniaux J; et al. (1995). “Surgery for congenital mitral valve disease in the first year of life”. J Thorac Cardiovasc Surg. 109 (1): 164–74, discussion 174-6. doi:10.1016/S0022-5223(95)70432-9. PMID 7815793.

[pmid7503011-22] Banerjee A, Kohl T, Silverman NH (1995). “Echocardiographic evaluation of congenital mitral valve anomalies in children”. Am J Cardiol. 76 (17): 1284–91. PMID 7503011.

[pmid3711511-23] Sullivan ID, Robinson PJ, de Leval M, Graham TP (1986). “Membranous supravalvular mitral stenosis: a treatable form of congenital heart disease”. J Am Coll Cardiol. 8 (1): 159–64. PMID 3711511.

[pmid22030961-24] Subramaniam V, Herle A, Mohammed N, Thahir M (2011). “Ortner’s syndrome: case series and literature review”. Braz J Otorhinolaryngol. 77 (5): 559–62. PMID 22030961.

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Health Dictionary

Tricuspid stenosis differential diagnosis

Introduction

Overview

Differential Diagnosis

References