Surgical Intervention for Isolated Tricuspid Valve Endocarditis-Refining Patients' Selection.

Tricuspid valve (TV) infective endocarditis (IE) is a known complication of intravenous drug use (IVDU). This study assessed long-term outcomes of surgically and medically treated cases of TV IE. This was a retrospective cohort study of all cases of native TV IE treated in London, Ontario between 2008 and 2011. Outcomes for medically and surgically managed cases were assessed at two years. Outcomes related to the timing of surgery were also assessed. Thirty-eight patients were included; seven received valve surgery: five repairs, two replacements. All patients had a history of IVDU. Baseline characteristics were equal in both groups. Death at two years was 43% in the surgical group and 26% in the nonsurgical group (p = 0.522). In those who received surgery within 30 days versus after 30 days from admission, death was 33% and 50%, respectively (p = 1.00). No patients received emergent surgery (within seven days of admission). Twenty-nine percent of the surgical group survived disease free versus 52% of the nonsurgical group. Survival with morbidity was mainly related to ongoing IVDU. The highest risk for mortality in both groups was ongoing IVDU. In IVDU-related TV IE the highest risk for mortality appears to be ongoing IVDU and persistent or recurrent endocarditis.

Objective: Compared with the extensive data on left sided infective endocarditis, right-sided infective endocarditis (RSIE) remains a rare condition. It accounts for 5–10% of all cases of infective endocarditis (IE) [1] [2] [3].Although it is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV infections often coexist, rheumatic heart disease remains the most important predisposing factor for IE in our context. The aim our study is to report clinical, investigation, management and outcome data in 5 patients diagnosed with RSIE in our department during the last 2 years. Methods: A retrospective analysis of data of 5 patients with right sided endocarditis in a tertiary care center from 2018 to 2020 was done. Results: All of our patients were young aged females none of them had cardiac devices or history of drug use. Persistent fever was the most common clinical presentation. Interestingly, 4 patients presented clinical heart failure. 3 patients had isolated tricuspid valve IE, one patient had isolated pulmonary valve IE, and one patient have both tricuspid and pulmonary valve IE. Blood cultures were negative in two cases, whilst two others were positive to Streptococcus (alpha) and one positive to Staphylococcus. 4 patients underwent surgical treatment after well conducted antibiotic therapy the indications were the presence of right heart failure secondary to severe tricuspid regurgitation and the size of the vegetations. Unfortunately, one patient died of massive pulmonary embolism despite well conducted antibiotherapy. Conclusion: RSIE is rare and occurs in a wide range of underlying conditions like implantable electronic devices, indwelling catheters, CHD and immune compromised state. Surprisingly, it can occur in young individuals without known risk factors. In our context, rheumatic heart disease remains the most incriminated etiology which lead us to question three essential points: 1. The interest of antibiotic prophylaxis in young patients with VSDs 2. The use of empiric antibiotics with action against streptococcus 3. Early surgical treatment in rheumatic heart disease.

Surgical treatment of isolated tricuspid valve infective endocarditis: 25-year results from a multicenter registry

Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis

Current Outcomes for Tricuspid Valve Infective Endocarditis Surgery in North America

MRSA tricuspid valve infective endocarditis with multiple embolic lung abscesses treated by combination therapy of vancomycin, rifampicin, and sulfamethoxazole/trimethoprim

Isolated tricuspid valve infective endocarditis (TVIE) is a rare clinical condition. Thus, there is no common consensus for the treatment options for TVIE. Vege-tectomy and valvulectomy, valve repair, and valve replacement, which are controversial in regard to hemodynamic consequences in right-sided low-pressure system and long-term prognosis. We present 2 young intravenous drug users with TVIE and our surgical strategy.

To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement. Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30 days after surgery) and long-term survival free from TVIE recurrence. A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1 years (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20 years (80 ± 6% Repair Group vs 59 ± 13% Replacement Group, P = 0.3). Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Optimal surgical treatment of infective tricuspid valve endocarditis in patients with intravenous drug use (IVDU) remains controversial. Tricuspid valvectomy has been proposed for infective tricuspid valve endocarditis in this patient population given the inherent social concerns. The aim of this systematic review and meta-analysis was to compare outcomes of valvectomy versus replacement for the surgical treatment of isolated infective tricuspid valve endocarditis. An electronic search was performed to identify all relevant studies published. After assessment for inclusion and exclusion criteria, 16 original studies were pooled for systematic review and meta-analysis. There were a total of 752 patients with infective tricuspid valve endocarditis, of which 14% underwent valvectomy and 86% underwent replacement (mean follow-up 4.2 years, 95% CI, 1.9-6.4 years). The most common indications for surgical intervention were septic pulmonary embolism in the valvectomy group (74%, 95% CI, 28-95%) and persistent sepsis in the replacement group (62%, 95% CI, 31-86%). There were no differences in rates of stroke [valvectomy 4% (95% CI, 1-11%) vs. replacement 3% (95% CI, 1-16%), P=0.85] but there was increased likelihood of prolonged ventilation in those who underwent valvectomy [valvectomy 40% (95% CI, 30-51%) vs. replacement 26% (95% CI, 23-30%), P<0.01]. There were no differences in 30-day post-operative mortality [valvectomy 13% (95% CI, 5-30%) vs. replacement 7% (95% CI, 5-10%), P=0.21], post-operative right heart failure [valvectomy 27% (95% CI, 10-53%) vs. replacement 11% (95% CI, 5-25%), P=0.17] and recurrent endocarditis [valvectomy 7% (95% CI, 2-23%) vs. replacement 19% (95% CI, 12-28%), P=0.81]. Valvectomy had a higher rate of tricuspid valve reoperation [valvectomy 56% (95% CI, 15-90%) vs. initial replacement 14% (95% CI, 7-27%), P=0.06]. Tricuspid valvectomy is an acceptable initial therapy for infective tricuspid valve endocarditis in patients with IVDU, providing a bridge to identify those who will self-select as candidates for staged valve replacement.

Septic pulmonary embolism (SPE) with isolated tricuspid valve infective endocarditis (TVIE) after an unsafe abortion is an uncommon condition. However, unsafe abortion is common among reproductive-age women, especially in underdeveloped and developing countries contributing significantly to increased maternal mortality. As infective endocarditis and SPE are likely to be missed in transthoracic echocardiography and chest X-ray, respectively, in its incipient stage, there is a possibility that many cases of SPE with TVIE following such a predisposing condition may remain undiagnosed. We report a case of 26-year-old female with recent unsafe abortion who was diagnosed to have SPE with TVIE. Her clinical course depicts the possibility of missing the diagnosis, especially if subtle findings are overlooked that are emphasized in this case report.

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

Background: Left ventricular dysfunction (LVD) can occur immediately after mitral valve repair (MVr) for degenerative mitral regurgitation (DMR) in some patients with normal preoperative left ventricular ejection fraction (LVEF). This study investigated whether forward LVEF, calculated as left ventricular outflow tract stroke volume divided by left ventricular end-diastolic volume, could predict LVD immediately after MVr in patients with DMR and normal LVEF. Methods: Echocardiographic and clinical data were retrospectively evaluated in 234 patients with DMR ≥ moderate and preoperative LVEF ≥ 60%. LVD and non-LVD were defined as LVEF < 50% and ≥50%, respectively, as measured by echocardiography after MVr and before discharge. Results: Of the 234 patients, 52 (22.2%) developed LVD at median three days (interquartile range: 3–4 days). Preoperative forward LVEF in the LVD and non-LVD groups were 24.0% (18.9–29.5%) and 33.2% (26.4–39.4%), respectively (p < 0.001). Receiver operating characteristic (ROC) analyses showed that forward LVEF was predictive of LVD, with an area under the ROC curve of 0.79 (95% confidence interval: 0.73–0.86), and an optimal cut-off was 31.8% (sensitivity: 88.5%, specificity: 58.2%, positive predictive value: 37.7%, and negative predictive value: 94.6%). Preoperative forward LVEF significantly correlated with preoperative mitral regurgitant volume (correlation coefficient [CC] = −0.86, p < 0.001) and regurgitant fraction (CC = −0.98, p < 0.001), but not with preoperative LVEF (CC = 0.112, p = 0.088). Conclusion: Preoperative forward LVEF could be useful in predicting postoperative LVD immediately after MVr in patients with DMR and normal LVEF, with an optimal cut-off of 31.8%.

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Adler), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. Patient presentation: Mr H is a 61-year-old man with a medical history significant for hypertension, hyperlipidemia, and benign prostatic hyperplasia who was admitted to the medical service with a chief complaint of fevers. Eleven years before presentation, the patient underwent a prostate biopsy for a rapidly rising prostate-specific antigen, and there was no evidence for malignancy. The biopsy was complicated by septicemia, which was treated with antibiotics. Four months before admission, the patient presented to the urology clinic with worsening urinary retention, and the decision was made to proceed to transurethral resection of the prostate. A preoperative workup was significant only for a urine culture growing 1000 colonies of enterococcus, and no antimicrobial treatment was given. He underwent a technically successful transurethral resection of the prostate and was discharged home the next day after passing a voiding trial. Two days after being discharged, the patient had fevers to 102°F and was readmitted to the hospital. He was found to have an Enterococcus faecalis urinary tract infection and was treated with 1 day of intravenous cefepime before being discharged the next day on a 7-day course of amoxicillin–clavulanic acid. On the day after discharge, blood cultures that were drawn on admission grew E faecalis with the same susceptibility pattern cultured from the urine, but there was no alteration in the treatment plan. The patient’s fevers resolved. One month before admission, the patient presented to an outside emergency department with decreased exercise capacity, pleuritic back pain, and malaise. Computed tomography of the chest with contrast identified a right …

Percutaneous Mechanical Aspiration Versus Surgical Management of Tricuspid Valve Endocarditis: A Systematic Review and Updated Meta-Analysis.