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

Abstract

SESSION TITLE: Cardiovascular Surgery Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: Tricuspid valve infective endocarditis (TVIE) is most commonly associated with intravenous drug use (IVDU), which on failing medical management, is treated via various surgical modalities (1,2). Tricuspid valve replacement (TVR) is the preferred treatment of choice in patients presenting with recurrent TVIE of prosthetic valves (3).CASE PRESENTATION: A 46-year-old man with a long history of infective endocarditis (IE) secondary to intravenous drug use (IVDU), who had undergone TV replacement twice before, presented with IE of the prosthetic valve for the third time, despite reported abstinence from IVDU. Fungemia, which is challenging to clear, in addition to bacteremia, was hypothesized to be one of the reasons for this complication. He was treated with intravenous antibiotics, following which he was switched to oral suppressive therapy. However, despite adequate medical management with Vancomycin and Micafungin for a period of over one year, a transesophageal echocardiogram (TEE) showed the presence of highly mobile vegetation measuring 2.1 cm x 1.5 cm on the TV prosthesis. He was then operated on for the third time for TV replacement within a span of 16 months from his first episode of IE. His condition remained stable after being discharged from his third TV replacement surgery, following which he was set up for cardiac rehabilitation with cardiology and infectious disease specialists.DISCUSSION: The 2015 European Society of Cardiology (ESC) guidelines recommend surgery if the IE is caused by micro-organisms that are difficult to eradicate (e.g., fungi), if bacteremia persists beyond seven days despite adequate antimicrobial therapy, in persistent TV vegetations larger than 20 mm after recurrent pulmonary emboli, and patients with right-sided heart failure due to severe tricuspid regurgitation, with poor response to diuretic therapy. According to the American College of Cardiology (ACC) 2015 update for IE in adults, early valve surgery is recommended in - prosthetic valves for persistent bacteremia lasting greater than 5-7 days after appropriate antimicrobial therapy and prosthetic valve IE caused by fungi or highly resistant organisms. Surgical management is associated with a higher rate of reoperation in IE in IVDU (20%) than non-users (5%) and an increased mortality risk.CONCLUSIONS: To our knowledge, there has not been any case that required the TV to be replaced for the third consecutive time due to the recurrence of IE. We have highlighted that multiple replacements of the TV for TVIE can be safely undertaken without complications, provided there are strong indications for the same.Reference #1: Hussain ST, Witten J, Shrestha NK, et al. Tricuspid valve endocarditis. Ann Cardiothorac Surg. 2017;6(3):255-261. doi:10.21037/acs.2017.03.09Reference #2: Luc JGY, Choi JH, Kodia K, et al. Valvectomy versus replacement for the surgical treatment of infective tricuspid valve endocarditis: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2019;8(6):610-620. doi:10.21037/acs.2019.11.06Reference #3: Kadri AN, Wilner B, Hernandez AV, et al. Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016. J Am Heart Assoc. 2019 Oct;8(19):e012969. doi: 10.1161/JAHA.119.012969DISCLOSURES: No relevant relationships by Huzefa BhopalwalaNo relevant relationships by Adnan BhopalwalaNo relevant relationships by Nakeya DewaswalaNo relevant relationships by Subramanya shyam gantiNo relevant relationships by Amrin KharawalaNo relevant relationships by Vinayak MishraNo relevant relationships by Nishant Tiwarino disclosure on file for Pedro Torres; SESSION TITLE: Cardiovascular Surgery Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Tricuspid valve infective endocarditis (TVIE) is most commonly associated with intravenous drug use (IVDU), which on failing medical management, is treated via various surgical modalities (1,2). Tricuspid valve replacement (TVR) is the preferred treatment of choice in patients presenting with recurrent TVIE of prosthetic valves (3). CASE PRESENTATION: A 46-year-old man with a long history of infective endocarditis (IE) secondary to intravenous drug use (IVDU), who had undergone TV replacement twice before, presented with IE of the prosthetic valve for the third time, despite reported abstinence from IVDU. Fungemia, which is challenging to clear, in addition to bacteremia, was hypothesized to be one of the reasons for this complication. He was treated with intravenous antibiotics, following which he was switched to oral suppressive therapy. However, despite adequate medical management with Vancomycin and Micafungin for a period of over one year, a transesophageal echocardiogram (TEE) showed the presence of highly mobile vegetation measuring 2.1 cm x 1.5 cm on the TV prosthesis. He was then operated on for the third time for TV replacement within a span of 16 months from his first episode of IE. His condition remained stable after being discharged from his third TV replacement surgery, following which he was set up for cardiac rehabilitation with cardiology and infectious disease specialists. DISCUSSION: The 2015 European Society of Cardiology (ESC) guidelines recommend surgery if the IE is caused by micro-organisms that are difficult to eradicate (e.g., fungi), if bacteremia persists beyond seven days despite adequate antimicrobial therapy, in persistent TV vegetations larger than 20 mm after recurrent pulmonary emboli, and patients with right-sided heart failure due to severe tricuspid regurgitation, with poor response to diuretic therapy. According to the American College of Cardiology (ACC) 2015 update for IE in adults, early valve surgery is recommended in - prosthetic valves for persistent bacteremia lasting greater than 5-7 days after appropriate antimicrobial therapy and prosthetic valve IE caused by fungi or highly resistant organisms. Surgical management is associated with a higher rate of reoperation in IE in IVDU (20%) than non-users (5%) and an increased mortality risk. CONCLUSIONS: To our knowledge, there has not been any case that required the TV to be replaced for the third consecutive time due to the recurrence of IE. We have highlighted that multiple replacements of the TV for TVIE can be safely undertaken without complications, provided there are strong indications for the same. Reference #1: Hussain ST, Witten J, Shrestha NK, et al. Tricuspid valve endocarditis. Ann Cardiothorac Surg. 2017;6(3):255-261. doi:10.21037/acs.2017.03.09 Reference #2: Luc JGY, Choi JH, Kodia K, et al. Valvectomy versus replacement for the surgical treatment of infective tricuspid valve endocarditis: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2019;8(6):610-620. doi:10.21037/acs.2019.11.06 Reference #3: Kadri AN, Wilner B, Hernandez AV, et al. Geographic Trends, Patient Characteristics, and Outcomes of Infective Endocarditis Associated With Drug Abuse in the United States From 2002 to 2016. J Am Heart Assoc. 2019 Oct;8(19):e012969. doi: 10.1161/JAHA.119.012969 DISCLOSURES: No relevant relationships by Huzefa Bhopalwala No relevant relationships by Adnan Bhopalwala No relevant relationships by Nakeya Dewaswala No relevant relationships by Subramanya shyam ganti No relevant relationships by Amrin Kharawala No relevant relationships by Vinayak Mishra No relevant relationships by Nishant Tiwari no disclosure on file for Pedro Torres;