The tricuspid valve has three leaflets - anterior, posterior, and septal. It is supported by chordae tendineae attached to papillary muscles. The septal leaflet develops last and is relatively immobile. The anterior and posterior leaflets act together like a bicuspid valve during diastole. The tricuspid valve annulus is saddle-shaped and less defined compared to the mitral valve. Proper placement of sutures and prostheses is important due to the tricuspid valve's relationships with surrounding structures like the conduction system and coronary sinus.

1. NORMAL ANATOMY OF
TRICUSPID VALVE
The forgotten valve
“Cinderella” of all cardiac valves

3. Tricuspid valve
• The tricuspid valve is part of a complex functional system that
also includes the right atrium, the right ventricle, and the
pulmonary circulation.
• It is generally a three-leaflet valve with an annulus and its
valvular plane facing toward the right ventricular apex

4. DEVELOPMENT

5. TRICUSPID VALVE DEVELOPEMENT
• DEVELOPMENT OCCURS IN TWO
PHASES:-
• FIRST PHASE- CONNECTION OF RIGHT
ATRIUM WITH RIGHT VENTRICLE
• SECOND PHASE- INVOLVES THE FORMATION
OF THE VALVAR LEAFLET WITH THEIR
TENSION APPARATUS

9. DEVELOPMENT OF TRICUSPID VALVE
• TV develops from two components
- Endocardial tissue of AV canal.
-Ventricular musculature( myocardial gully/
tricuspid gully)

10. Tricuspid gully complex
• Remodelling of the tissue of the right atrio-
ventricular junction produces a myocardial
gully that guards the inferior portion of the
ventricular inlet
• The muscular conduit thus formed was
initially termed the “tricuspid gully”

11. • Inferior and lateral wall of this gully together
with right endocardial cushion form the
inferior leaflet.
• Septal leaflet develop from ventricular septum
and postero-inferior part of endo-cardial
cushion.
• Anterior leaflet formed from supraventricular
crest

12. • The separation of the trabecular layer sets the
scene for formation :-
• Anterosuperior and inferior leaflets of the
tricuspid valve, along with their supporting
tension apparatus.
• Septal, leaflet of the tricuspid valve, along with
its tension apparatus, is delaminated at a
much later stage from the right ventricular
aspect of the developing ventricular septum.

13. • Developmental process leads to delamination
of the underlying myocardium during 8-12
weeks.
• Delamination progress from posterior leaflet
and development of this leaflet at 8 weeks to
anterior leaflet (11 weeks) and finally to septal
leaflet(12 weeks).

15. Congenital - EBSTEIN ANOMALY
Characterized by
• Adherence of the septal and posterior leaflets to
the underlying myocardium (failure of
delamination, namely splitting of the tissue by
detachment of the inner layer during embryologic
development)
• Downward (apical) displacement of the
functional annulus (septal> posterior> anterior)

18. TRICUSPID VALVE COMPLEX
- Annulus
- Three valve leaflets
- Supporting chordae tendineae
- Papillary muscles
- Part of Right atrium and right ventricular myocardium

19. ANNULUS

21. TV annulus
-Annulus is a heterogeneous ,almost
virtual ,structure composed of
intermixed fibrotic and elastic fibers
in continuity with the leaflet tissue ,
the atrium, and the ventricle .
-Complex 3 D structure, Nonplaner ,
elliptical-saddle shaped annulus.
-The annulus fibrosus is not visible
from atrial view because it is deeper
and 2mm external to the hinge.

22. • More a landmark rather than fibrous ring
• Absence of encircling fibrotic structure
explains the large changes in the tricuspid
orifice continuously during cardiac cycle.
• Reduction in orifice perimeter is not uniform
and annulus corresponding to septal leaflet
reduces least while maximum reduction occur
in posterior leaflet.

24. TV annulus
• DURING DIASTOLE –GROSSLY CIRCULAR
• DURING SYSTOLE – THE ATRIO-VALVULAR JUNCTION HAS AN
OVOID SHAPE
• Normal circumference of TV annulus in adults is 11±2 c.m.
• Normal area of tricuspid valve is 7-10 cm2.
• Normal diameter in 4 chamber view is 28±5 c.m.
• Size of TV change dramatically during cardiac cycle
• Maximum size just before atrial systole
In Mid systole reduced to 10±1 c.m.
(19% reduction in circumference and 33 % reduction in area)

25. During disease conditions, the saddle-shaped
annulus enlarges, becoming circular, and the
corresponding change in the annulus area
typically serves as a predictor of valve
disorders such as tricuspid regurgitation .

26. • Structurally, the annulus forms the base of the TV leaflets and is
composed of two types of discontinuous segments—muscular
annulus and collagen-rich fibrous annulus .
• The muscular annulus is formed of a circumferentially oriented
myofiberous lamina and a second lamina formed of myofibers
perpendicular to the circumferential myofibers .
• Racker et al. (1991)described that the anterior, lateral, and
posterior regions of the TV annulus are completely encircled with
circumferential myofibers with only a thin muscular connection at
the medial region of the TV annulus. The fibrous annulus forms the
antero-medial regions and continues with the connective tissues
into the TV leaflets.
• Microscope-based study of the human TV annulus indicated the
presence of myofibers in the posterior and anterior annulus and
collagen bundles in the septal annulus
•

30. Fibrous Skeleton
• Rt fibrous trigone brings both MV and AOV
into fibrous continuity with TV.
• This part of fibrous skeleton includes the
membranous septum which separates the
LVOT from right heart chamber.
• Septal leaflet inserts obliquely across the
septum.
• This insertion of septal leaflet is 10-15 mm
low(apically placed) compare to MV and
divides membranous septum into
atrioventricuar and interventricuar
components.

31. Fibrous Skeleton

33. TV leaflets
• THREE LEAFLETS

34. The TV annulus transitions into three leaflets:
• Anterior leaflet
• Posterior leaflet
• Septal leaflet
• In general, the TV leaflets have a rough zone in the crescentic region
where chordae tendineae are attached, a broad basal zone at the apex
of the leaflet, and a clear zone.

35. • The TV leaflet tissue layers are composed of
extracellular matrix proteins—elastin, collagen,
proteoglycans (PGs), and glycosaminoglycans
(GAGs) populated with dynamic valvular interstitial
cells (VICs).
• The connective tissue structure is organized into
four morphologically and biomechanically distinct
layers known as the:
• Atrialis (A)
• Spongiosa (S)
• Fibrosa (F)
• Ventricularis (V)
HISTOLOGY

37. • A dense, collagenous fiber network
distinguishes the main load bearing layer of
the leaflets, the fibrosa, from the surrounding
tissue.
• The ventricularis, anatomically situated below
the fibrosa and facing the ventricular side of
the heart, is rich in circumferentially oriented
elastin fibers that assist in the stretching and
recoiling of the valve tissue.

38. • The spongiosa layer is rich in hydrophilic
GAGs and PGs that act as a dampening
mechanism during rapid leaflet bending
• The atrialis layer—on the atrial side of the
leaflet—is composed of elastin, collagen and
GAGs, and this layer of the TV leaflets is
reported to have a high innervation density

39. • In addition, VICs are
heterogeneous, dynamic cells
distributed throughout the leaflets’
layers .
• VICs play a major role in
maintaining the structural integrity
of the leaflet tissues by regulating
the extracellular matrix (ECM)
scaffold remodeling.
• Different VIC phenotypes express
molecular markers found in
myofibroblast and smooth muscle
cells (SMCs).
• The activated VICs produce
myofibroblasts and express smooth
muscle α-actin as well as other
contractile proteins commonly
found in the vascular SMCs .
• It has also been shown that the MV
leaflet VICs are stiffer than the cells
in the TV leaflets, implying a
correlation between the VIC-
regulated collagen biosynthesis
and transvalvular pressure loading

40. • Anterior leaflet- also known as infundibular
leaflet, superior leaflet or greater leaflet.
• Semicircular but may be quadrangular.
• Largest in all leaflet , attached to right
ventricular outflow tract
LEAFLETS OF TV

41. Leaflets of TV
• Posterior leaflet- also known as marginal, dorsal or inferior
leaflet
• Roughly trapezoidal shape.
• Inserted on one third of the circumference of the annulus
• Leaflet has several indentations or clefts in its free edge that
give it a scalloped appearance.
(predominantly three)

42. Leaflets of TV
• Septal leaflet- also called medial leaflet.
• Smallest leaflet.
• Semioval in shape.
• Attached to the right fibrous trigones and the
atrial and ventricular septa.
• These fibrous attachments make this leaflet
relatively immobile.

43. Leaflets of TV
• Because septal leaflet is relatively immobile
most of the annular descent takes place along
the margin of anterior and posterior cusp.
• During diastole anterior and posterior cusps
move like sail to meet septal leaflet so
functionally TV acts as bicuspid valve.

45. Leaflet of TV
• LEAFLET HAS THREE ZONES
1. Rough zone-area between its free edge
and line of closure.
2. Basal zone- usually 2 mm wide area
extends from the annulus to clear zone.
3. Clear zone- between these two zone.

46. Commisures
Three commisures
• ANTERO SEPTAL COMMISURE-
- Between anterior and septal leaflet
-Chordae is short and arises directly from
septal band or small papillary muscle.
- Basal attachment of TV at this commisure is
highest level at membranous septum.

47. Commisures
• ANTEROPOSTERIOR COMMISURE
- Between anterior and posterior leaflet
- Located roughly at acute margin of RV
- Large anterior papillary muscle identifies this commisure.
POSTEROSEPTAL COMMISURE
-Between posterior and septal leaflet
- Large chordae, papillary muscle and fold in septal leaflet
- Posteroseptal commisure has the widest spread
Free edge of commisural areas forms smooth arch.

48. Commissures Defined by the presence of Fan chords

50. Chordae tendinae
• Five types
- FAN shaped chordae- Inserts into commisure
and cleft
- Rough zone chordae- inserts into rough zone
of TV, divides into three prior to insertion.
One at free edge, other at upper limit of
rough zone and third between these two.

51. Chordae tendinae
- Free edge chordae- single, thread like, inserts
at apex of leaflet.
- Deep chordae- long chordae inserts to rough
or clear zone.
- Basal chordae- usually single, arises directly
from myocardium or trabeculae. Inserts into
zone approx. 2 mm wide extending into the
leaflet from the annular region.

52. Chordae tendinae
• Average 25 chords inserts into the tricuspid
valve.
• Seven to anterior, six to posterior, nine to
septal and three into commisural areas.
• Fan shaped chordae inserts into cleft of
posterior leaflet and at interleaflet commisure
• Other four are common to all three leaflets.

58. TANDLERS CLASSIFICATION

60. Papillary muscles
Classically, three groups of papillary muscles
–
•Anterior papillary muscle
•Posterior papillary muscle
•
•Septal papillary muscle
These are present in the right ventricle,
bearing fibrous chordae tendineae, which
support the adjacent cusps of the tricuspid
valve and prevent their reversion and re-
gurgitation during systole.
Trabeculae carneae, which are irregular muscular ridges and projections in the
ventricular cavity, lined by the endocardium, are of varying type like free, fixed and
papillary muscles.

61. •The anterior papillary muscle is the largest and arises from the anterior wall
•The posterior papillary muscle is frequently bifid or trifid and arises from the inferior wall
of right ventricle.
•Third smaller and most variable septal papillary muscle has a medial position, attached
to the ventricular septum

63. • According to a more recent functional terminology
for the tricuspid valve, the papillary muscles can be
grouped according to the distribution of their cords
to a definite commissure and its contiguous main
leaflets.
• Therefore, the APM becomes the anteroposterior,
the PPM the posteroseptal and the SPM the
anteroseptal papillary muscle, respectively
(Joudinaud et al., 2006).

65. TRICUSPID VERSUS MITRAL VALVE
TRICUSPID VALVE MITRAL VALVE
1) TRICUSPID BICUSPID VALVE
2) LARGE IN DIAMETER DIAMETER SMALL COMAPRE TO TV
3) MORE CHANGES DURING CARDIAC
CYCLE
BECAUSE OF FIBROUS SKELETON LESS
CHANGES IN ANNULUS
4) EXTENSIVE CHORDAL SUPPORT BUT
LESS UNIFORM
MORE UNIFORM CHORDAL SUPPORT
5) PAPILLARY MUSCLE AT COMMISURE
ARE INCONSISTENT
PAPILLARY MUSCLE SUPPORT GOOD AND
CONSISTENT
6) BASAL CHORDAE PRESENT IN ALL
LEAFLETS
BASAL CHORDAE PRESENT IN ONLY
POSTERIOR LEAFLET
7) CHORDAE INSERTS AT VENTRICULAR
WALL
CHORDAE NEVER INSERTS TO
VENTRICULAR WALL

66. TRICUSPID VERSUS MITRAL VALVE
TRICUSPID VALVE MITRAL VALVE
8) RARELY AFFECT IN ISOLATION COMMONLY AFFECT IN ISOLATION
9) WORKS IN LOW PRESSURE SYSTEM WORKS IN HIGH PRESSURE SYSTEM

69. Relation with other structure
• Related to conduction system
• Right coronary artery
• Coronary sinus
• Aortic root

70. Conduction system
• – Triangle of Koch:
The triangle of Koch is the home of the
Atrioventricular node.
1. Inferior border is Todaro's tendon
2. Superior border is the septal leaflet of the
tricuspid valve.
3. The base is the coronary sinus.

71. Conduction system

72. Conduction system
• Bundle of HIS is direct continuation of AV
node.
• Passes through the rightward part of central
fibrous body to reach to the posteroinferior
margin of membranous ventricular septum.
• This area is just inferior to commisure
between septal and anterior leaflet of TV.

73. Conduction system
When repairing the
tricuspid valve, an open
"C" ring avoids the
necessity of suturing
near the AV Node
making complete heart
block less likely

75. Coronary artery
• Right coronary artery runs parallel to the
atrioventricular groove.
• Although injury to RCA is very rare but one
should always careful while taking suture in
this area.

77. CORONARY SINUS
• Coronary sinus situated above the
posterosetal commisure and close to the right
fibrous trigone.
• Place suture safely and avoid damage to
coronary sinus.

79. RIGHTVENTRICLEANATOMY,PHYSIOLOGY,ASSESSM ENT& CLINICALSIGNIFICANCE
ANATOMY
• Crescentshapedchamber
• Assuggested by “Goor and Lillehi”,
• Inlet
• Trabecular
• Outflow/Conus/
Infundibulum

80. RIGHTVENTRICLEANATOMY,PHYSIOLOGY,ASSESSMENT& CLINICALSIGNIFICANCE

81. RIGHTVENTRICLEANATOMY ,PHYSIOLOGY,ASSESSMENT& CLINICALSIGNIFICANCE
•
Within the right ventricle, anearly circular ringof
muscleknown asthe crista supraventricularis
(supraventricularcrest) forms anunobstructed opening
into the outlet region.It consistsof –
Parietal band
Outletseptum
•
•
•
•
Septal band, and
Moderator band

82. RIGHTVENTRICLEANATOMY,PHYSIOLOGY,ASSESSMENT& CLINICALSIGNIFICANCE

84. Aortic valve
• Anteroseptal commisure is very close to the
non coronary sinus of aortic valve,
placing the aortic prosthesis prior to TV
prosthesis at this level can lead to injury,
which will be difficult to repair in presence of
aortic prosthesis so that always
• So always perform tricuspid valve procedure
first.

86. TV DISEASE
• Can be classified in two group
• 1) Functional
• 2) organic TV DISEASE

87. Tricuspid regurgitation
• Functional TR 
-occurs in left heart disease
-severe PAH
Leaflet and chordae remains normal.
TR because annulus dilated and fails to shortens during
systole.
septal leaflet affects least in functional TR because-
1) fixed at right fibrous trigone
2) Attached to ventricular septum
posterior leaflet changed maximum in TR .
Kings et al reported 66% of sev TR patient came for surgery
had mild TR at MV surgery.

88. Disproportional dilation of tricuspid annulus in secondary tricuspid
regurgitation. Dilation develops in the area of anterior and posterior
leaflets. Annulus does not dilate in the area of septal leaflet.

89. TV regurgitation

90. ORGANIC TV disease

91. Organic TV disease
• Endocarditis 5-10 % of all cases of IE.
- More common in IV drug abuser
- because its located prior to lung filter so
-lesion vary from isolated vegetation to total
destruction of annulus.
- vegetation usually present at the tip of leaflet
or towards the atrial side( conservative
surgery possible).

92. Organic TV disease
• Rheumatic isolated TV involvement very
rare .
- Typical lesion show leaflet thickening with
commisural fusion.
- Subvalvular apparatus rarely affected and
cacification very rare.
- Classical lesion is stenosis but regurgitation
also equally present.

93. Organic TV disease
TV

94. Congenital - EBSTEIN ANOMALY
Characterized by
• Adherence of the septal and posterior leaflets to
the underlying myocardium (failure of
delamination, namely splitting of the tissue by
detachment of the inner layer during embryologic
development)
• Downward (apical) displacement of the
functional annulus (septal> posterior> anterior)

95. Ebstein…
(3) dilation of the “atrialized” portion of the right
ventricle, with various degrees of hypertrophy and
thinning of the wall.
(4) redundancy, fenestrations, and tethering of the
anterior leaflet .
(5) dilation of the right atrioventricular junction (true
tricuspid annulus)

96. Ebstein anomaly
• Anterior leaflet is usually large and billowy
(sail like).
• its chordae are fused short and deformed.
• It is least displced as compared to septal and
posterior leaflet.
• The downward displacement of the septal
and posterior leaflets in relation to the
anterior mitral valve leaflet is 8 mm/m2 body
surface area in normal heart.

97. Ebstein anomaly
• In Ebstein’s anomaly, the RV is divided into 2 regions:
1) the inlet portion, which is functionally integrated
with the right atrium,
2) trabecular and outlet portions, that constitute the
functional right ventricle.
There is often marked dilatation of the true tricuspid
valve annulus, which is not displaced, and a large
chamber separating this true annulusfrom the functional
RV.
The RCA demarcates the level of the true annulus and
may become kinked during plication annuloplasty
procedures.

98. Ebstein anomaly
During atrial contractionatrialized portion of
RV in diastole and balloon out( taking up a
large portion of blood volume to be ejected)
During ventricuar systole atrialized RV
contracts and creates pressure wave in normal
RA.
OVERALL effect leads to gross RA dilatation 
this dilatation increases TV incompetence.

99. ANOMALIES OF TV
• STRADDLING OF TV when a part of tension
apparatus of the valve crosses the VSD and
attached to the septum or VSD of the opposite
ventricle.
• OVERRIDING  when atriventricular junction
is connected to both ventricles.