Audience: echocardiographers, cardiology trainees and valve teams. Evidence reviewed: September 2026.
Key message
Tricuspid stenosis is uncommon and usually coexists with regurgitation or left-sided valve disease. Diagnosis requires anatomy, haemodynamics and loading conditions to agree; a gradient alone is insufficient.
Anatomy first
The tricuspid apparatus comprises a large non-planar annulus, leaflets, chordae, papillary muscles, right ventricle and right atrium. Three-dimensional imaging often identifies anterior, posterior and septal leaflet segments more reliably than a single two-dimensional plane. Describe leaflet thickening, doming, restriction, commissural fusion, calcification, subvalvular involvement and device-lead interaction.
Causes
- Rheumatic disease, often with mitral involvement.
- Carcinoid heart disease.
- Congenital abnormality or prior repair.
- Endocarditis-related destruction or obstruction.
- Device leads, intracardiac masses and rare drug-related disease.
Echocardiographic approach
| Question | Method | Caution |
|---|---|---|
| Is the valve anatomically restricted? | Multiple 2D views; 3D en-face imaging where feasible | Do not infer stenosis from colour aliasing alone. |
| Is inflow obstructed? | CW Doppler aligned with tricuspid inflow; average several beats | Gradient rises with heart rate and flow. |
| What is the consequence? | RA size, IVC/hepatic veins, RV size/function, systemic venous congestion | Coexistent TR may dominate haemodynamics. |
| Is another lesion driving flow? | Full valve and shunt assessment | Pregnancy, anaemia and left-sided disease alter gradients. |
Acquire CW Doppler from the window with the most parallel inflow alignment, commonly apical or parasternal RV inflow. Use a slow sweep speed and measure at end-expiration when appropriate. Average at least three beats in sinus rhythm and more in atrial fibrillation. Report heart rate with the mean gradient. Valve area by pressure half-time is less robust for the tricuspid valve and is influenced by right-sided compliance and loading.
Severity and clinical integration
Severe disease is supported by clear anatomical restriction, persistently raised mean diastolic gradient at a stated heart rate, prolonged inflow, reduced valve area where measurement is credible, right-atrial enlargement and systemic venous congestion. Discordant data should trigger image review and, when necessary, transoesophageal echo, CT, CMR or invasive haemodynamics.
The 2025 ESC/EACTS guideline recommends intervention for symptomatic severe tricuspid stenosis and supports tricuspid surgery when severe stenosis is present during left-sided valve surgery. Decisions should be made by a multidisciplinary valve team, accounting for aetiology, regurgitation, RV function, pulmonary vascular disease and operative risk.
Reporting checklist
- Aetiology and leaflet/subvalvular morphology.
- Mean gradient, heart rate, rhythm and number of beats averaged.
- Degree and mechanism of associated TR.
- RA/RV remodelling, RV systolic function and estimated right-atrial pressure.
- Other valve lesions and evidence of systemic congestion.
Selected references
- 2025 ESC/EACTS valvular-heart-disease guideline.
- 2025 ESC/EACTS guideline—PubMed record.
- BSE guideline for tricuspid and pulmonary valve echocardiography.
Educational material only. Valve-intervention decisions require specialist multidisciplinary assessment.
The Cardiac Compass 