2/10/2016

TricuspidValveAnatomy:Overview,GrossAnatomy,MicroscopicAnatomy
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TricuspidValveAnatomy
Author:NyalEBorges,MDChiefEditor:RichardALange,MD,MBAmore...
Updated:Jun27,2016

Overview
Therightatrioventricularvalvecomplex(thetricuspidvalve)ismadeupofthe3
valveleaflets,theannulus,thesupportingchordaetendineae,andthepapillary
muscles.Theatrialandventricularmasses,conductionsystemtissue,andsupport
structureofthefibroelasticcardiacskeletonallowcoordinatedactionsofthe
tricuspidvalve. [1]Seethefollowingimages.

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Surfaceanatomyoftheheart.A=aorticvalveM=mitralvalveP=pulmonicvalveT=
tricuspidvalve.

Heartvalves,superiorview.

Thetricuspidvalveisoftencalledthe"forgottenvalve"or"lostvalve,"becauseitis
understudiedrelativetotheothercardiacvalvesvariationsinanatomicstructures
havebeenreportedintheliterature.Thetricuspidvalvehasbeendescribedas
havingasfewas2andasmanyas6leaflets, [2]whereasthepapillarymuscleshave
beenreportedtonumberfrom2to9. [3]

GrossAnatomy
Thetricuspidvalveislocatedbetweentherightatriumandrightventricleandhasa
valveareaof46cm 2(seethefollowingimageandvideo). [4]Thevalveisnearly
verticalandisapproximately45tothesagittalplane.Thevalveitselfisslightly
inclinedtotheverticalsothatthemarginsofthevalveareanterosuperior,inferior,
andseptal,andthecuspstaketheirnamefromtheseattachmentsites. [1]

Thetricuspidvalve(TV)asviewedfromtherightatrium(RA).
HumanTV.CourtesyoftheVisibleHeartLabattheUniversityofMinnesota.

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Theanterosuperior(anteriororinfundibular)cuspisthelargestcuspofthe3andis
locatedbetweentheconusarteriosusandatrioventricularorifice.Theposterior
(marginal)cuspisthenextlargestcuspandisnamedforitsrelativeposterior
positionandisconnectedtotheposterioraspectoftherightventricle.Thethirdand
smallestcusp,theseptal(medial)cusp,isattachedtotherightandleftfibrous
trigonesandtheatrialandventricularsepta.Thesefibrousattachmentsmakethe
septalcusprelativelyimmobiletherefore,mostofthetricuspidannulardescent
takesplacealongthemarginsoftheanteriorandposteriorcusps. [1,4]During
diastole,themajorcusps(anteriorandposterior)movelikesailsandmeettojoin
thesmallerseptalleaflet.Thus,functionally,thetricuspidvalveactsmorelikea
bicuspidvalve. [1]
Thetricuspidsubvalvularapparatusconsistsofanterior,posterior,andseptal
papillarymusclesandtheirtruechordaetendineae.Falsechordaecanconnect2
papillarymuscles,connectapapillarymuscletotheventricularwall,orconnect
pointsontheventricularwalls.Thetruechordaetypicallyoriginatefromtheapical
thirdofthepapillarymusclebutcanoriginatefromtheventricularwalls,asisthe
casefortheseptalleaflet.
Theanteriorpapillarymuscleisthelargest,theposteriorisoftenbifidortrifid,and
theseptalisthesmallest.Thesepapillarymusclessupplythechordaeforthe
adjacentcomponentsofthecuspstheysupport.Theanteriorpapillarymuscle
provideschordaetotheanterioronlyortheanteriorandseptalleaflettheposterior
papillarymuscleprovideschordaetotheposteriorandseptalleafletsandtheseptal
papillaryprovideschordaetotheseptalandanteriorleaflets. [5]Characteristically,
theseptalleafletisalsosupportedbychordaethatarisefromtheventricular
septum. [1,4,6].
Functionally,thepapillarymusclescontractjustpriortotheonsetofrightventricular
systolesoastoincreasetensioninthechordaetendinaeandmaximizecoaptation
ofthe3cusps,therebyreducingregurgitationacrossthetricuspidvalve. [7]

MicroscopicAnatomy
Thetricuspidvalveisformedinweeks56ofembryonicdevelopment.Afterthe
atrioventricular(AV)endocardialcushionsfuse,eachatrioventricularorificeis
surroundedbylocalproliferationsofmesenchymaltissue,fromwhichtheAVvalves
formandareattachedtotheventricularwallbymuscularcords.Finally,muscular
tissueinthecordsdegeneratesandisreplacedbydenseconnectivetissuewiththe
valveitselfcoveredbyendocardium. [8]
ThefollowingimageshowstheAVvalveleafletanditsattachmenttothefibrous
skeletonoftheheart.TheAVvalveleafletisformedbyafoldorduplicationofthe
endocardiumadenseconnectivetissuecoreformsthecentralpartofthevalve
leaflet.Theupperoratrialsurfaceofthevalveisthickandresemblesatrial
endocardium,andthelowerorventricularsurfaceofthevalveisthinandresembles
ventricularendocardium.

Atrioventricularvalve(AV)histology.

PathophysiologicVariants
Ebsteinanomaly
Ebsteinanomalyoccursinapproximately1in200,000livebirths,accountsforless
than1%ofallcongenitalheartdiseases,andisassociatedwithmaternallithium
useduringthefirsttrimesterofpregnancy.Ebsteinanomalyischaracterizedbythe
following[9]:(1)adherenceoftheseptalandposteriorleafletstotheunderlying
myocardium(2)apicaldisplacementofthefunctionalannulus(3)dilatationofthe
"atrialized"portionoftherightventriclewiththinningofthewall(4)redundancy,
fenestration,andtetheringoftheanteriorleafletand(5)dilatationofthetrue
tricuspidannulus.(SeeEbsteinAnomaly.)

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Tricuspidatresia
Tricuspidatresiamaybedefinedasacongenitalabsenceoragenesisofthe
tricuspidvalvethisisthethirdmostcommoncauseofcyanoticcongenitalheart
defects.Thereare6formsoftricuspidatresiawithdifferingunderlyinganatomic
pathologyseeTricuspidAtresiaformoreinformation.

Congenitaltricuspidstenosis
Congenitaltricuspidstenosishasseveralmanifestations.Thetricuspidvalvemay
haveincompletelydevelopedleaflets,shortenedormalformedchordae,small
annuli,abnormalsizeandnumberofthepapillarymuscles,oranycombinationof
thesedefects. [10]Congenitaltricuspidstenosisisrareandisusuallyassociatedwith
otheranomalies,suchasseverepulmonarystenosisoratresiaandsecondary
hypoplasiaoftherightventricle. [11,10]

Congenitalcleftoftheanteriorleaflet
Congenitalcleftoftheanteriorleafletofthetricuspidvalveisrareandusually
associatedwithperimembranousventricularseptaldefects,pulmonarystenosis,or
atrialseptaldefects. [12]

ContributorInformationandDisclosures
Author
NyalEBorges,MDHughJacksonMorganChiefResident,InstructorofMedicine,DepartmentofMedicine,
VanderbiltUniversityMedicalCenter
NyalEBorges,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Physicians,PhiKappaPhi
Disclosure:Nothingtodisclose.
Coauthor(s)
JohnAMcPherson,MD,FACC,FACPProfessorofMedicine,SolandMarvinRosenblumChairinMedical
Education,ViceChairforEducation,DepartmentofMedicine,VanderbiltUniversityMedicalCenter
JohnAMcPherson,MD,FACC,FACPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanCollegeofCardiology,AmericanCollegeofPhysicians,AmericanHeartAssociation,Associationof
ProgramDirectorsinInternalMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
RichardALange,MD,MBAPresident,TexasTechUniversityHealthSciencesCenter,Dean,PaulLFoster
SchoolofMedicine
RichardALange,MD,MBAisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
CollegeofCardiology,AmericanHeartAssociation,AssociationofSubspecialtyProfessors
Disclosure:Nothingtodisclose.
AdditionalContributors
MichaelABarnett,MDFellow,DivisionofCardiovascularMedicine,VanderbiltUniversityMedicalCenter
Disclosure:Nothingtodisclose.
Acknowledgements
TheauthorwouldliketoacknowledgeArthurDalleyII,PhD,ProfessorandDirectoroftheMedicalGross
AnatomyProgramandFacilities,VanderbiltUniversitySchoolofMedicine,forhiscontributionstothisarticle.
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviousauthorJohn
AMcPherson,MD,FACC,FSCAI,tothedevelopmentandwritingofthisarticle.

References
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Anat.1990.12(1):3741.[Medline].
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tricuspidstenosis.CardiovascInterventRadiol.1990Dec.13(6):3546.[Medline].
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