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.
Tricuspid valve infective endocarditis is rare and accounts for 5% of infective endocarditis [
A 17-year-old boy was referred to our emergency unit with the complaint of high fever, dispnea, and palpitation for about a week. Echocardiography showed severe tricuspid regurgitation (TR) and vegetation on the tricuspid valve. He was diagnosed with isolated TVIE and underwent medical treatment in the emergency unit. Physical examination has shown that there was abdominal distention. Pulmonary oscultation has shown that there was a ral and roncus. Blood tests showed an inflammatory reaction with WBC count 28,400/μl and CRP level 9.25 mg/dl. Echocardiographic examinations showed a TR grade of 3 - 4 and mobile vegetation, 43 × 27 mm, on the tricuspid valve (
A 22-year-old intravenous drug user man was referred to our hospital with a history of fever, early fatigue and dispnea. He also complaintd of cough, and appetite loss for about 1 week. Echocardiography showed TR and
vegetation on the tricuspid valve. Isolated TVIE was diagnosed, and he underwent medical treatment. Physical examination was normal. Blood tests showed a inflammatory reaction with a WBC count of 16,500/μl and a CRP level of 5.35 mg/dl. Echocardiography showed TR grade 4 and mobile vegetation, 24 × 11 mm, on the tricuspid valve. There was a perforation on the anterior leaflet of the tricuspid valve. Chest CT demonstrated multiple infiltrates and cavitations in both lung fields and multiple pulmonary embolisms (
Operation was performed in the standard manner, on arrest with CPB. When the right atrium was opened, multiple vegetations were found attached to the anterior, septal leaflet of the tricuspid valve. Torn chordae were seen in the operation. Because the infection was generalized, and there was a valvular perforation a total resection of the tricuspid valve with its vegetation was performed. No.33 Carpentier-Edwards pericardial bioprosthesis (Edwards Lifesciences, Irvine, CA) was replaced. His postoperative course was uneventful. He remains well about 2 months after surgery with no recurrence of endocarditis.
The treatment of TVIE likes to left-sided endocarditis. After the diagnosis of TVIE, medical treatment with antibiotics is indicated. If the patients’ status is possible, medical management should be continued until signs of infection disappear for 4 to 6 weeks. The operative indications for TVIE in the active stage are severe tricuspid regurgitation, septic embolus, recurrent pulmonary embolism, and the presence of mobile vegetation of more than 10 mm [
proach was indicated because of septic recurrent pulmonary emboli from vegetations during the active stage.
In surgical treatment for TVIE, a complete debridement of infected tissue including the tricuspid valve and a reduction of tricuspid regurgitation are important to prevent the recurrence of endocarditis and right ventricular dysfunction after surgery.
In the literature, the surgical options are vegetectomy and valvulectomy [
A limited number of medical reports with regard to the outcome of valve replacement for TVIE has been found. Tokunaga et al. reported excellent long-term outcomes with isolated TVR in 31 patients with tricuspid valve disease whose operative mortality was 6.5% [
For optimal treatment in TVIE patients there are many of questions are waited the responces. The main question is: Are the mechanical or biologic valves better in regard to thrombosis or durability in the right-sided low pressure system? This question is controversial yet and is not being completely answered.
Although, it is standard procedure that operations are performed under CPB, some patients with TVIE cannot tolerate it because of severe lung injury as a result of pulmonary embolism. In our two patients, valvular repair was not possible. Thus, we chosed bioprosthetic tricuspid valve replacement for the tratment of TVIE. There is no side effect of the biologic valves during the follow-up period in both patients. If it is possible tricuspid valve repair is now the choice ofsurgical option for patients with TVIE. However, we believe that if tricuspid destruction is severe and not suitable for valve repair due to infection involves all three leaflets and the subvalvular apparatus tricuspid valve replacement is indicated.
We report 2 rare surgical cases of isolated TVIE in young drug users and clinical outcomes. We believe that tricuspid bioprosthetic valve replacement can be done safely for a surgical option in patients TVIE with regard to freedom of recurrence of endocarditis and valvular competence.