**7. Complications of tricuspid endocarditis**

The most common complications are related to valvular destruction with subsequent varying degrees of tricuspid regurgitation. Large vegetations can lead to valvular obstruction or recurrent septic pulmonary embolization (**Figure 1(A)**) and hemoptysis or pulmonary abscesses (**Figure 1(B)**). This repeat pulmonary embolization can result in elevation of the right-sided pressures, which in the presence of atrial level shunting, can lead to systemic embolization as well [21]. In severe cases, abscess formation is not uncommon [22], so as varying degrees of atrioventricular block. Acute diffuse glomerulonephritis secondary to immune complex formation and complement C3 deposition in the renal glomeruli resulting in acute renal failure

**Figure 1.**

*(A and B). Preoperative computed tomography scan in a patient with isolated tricuspid valve endocarditis secondary to intravenous drug use showing: (A) multiple bilateral septic pulmonary emboli with cavitation. Notice in (B), the development of necrotic changes with possible abscess (asterisk) formation in the left lung.*

has been reported with *Staphylococcus aureus* [23]. When sepsis is uncontrolled, this can lead to right heart failure, septic shock, and multiorgan failure.

Acquired VSD can occur after an episode of endocarditis. Gerbode described in 1958 [24] an acquired form of left ventricular-to-right atrial shunting with successful repair. Acquired Gerbode defect is a type of paramembranous VSD that is associated with left ventricular-to-right atrial shunting which can occur above (Type I), below (Type II) or both sides (Type III) of the septal leaflet of the TV [25].

### **8. Diagnosis**

Diagnosis depends on high index of suspicion and by identifying the patient's risk factors and the occurrence of the usual manifestation of infection such as persistent fever and other signs of bacteremia. Echocardiography remains the most appropriate initial test in these patients. Both transthoracic and transesophageal modalities are important to confirm the diagnosis, identify the presence of vegetations (**Figure 2**; **Video 1**—https://bit.ly/3mDCQxK), evaluate the degree of TV destruction/regurgitation (**Video 2**—https://bit.ly/3mDCQxK), rule out any intra-cardiac shunts and evaluate the left side of the heart for any evidence of multivalvular involvement.

#### **Figure 2.**

*A large tricuspid valve vegetation (1.9 × 1.2 mm) is shown on preoperative transthoracic echocardiography. RA: Right atrium; RV: Right ventricle.*

**163**

*Surgery for Tricuspid Valve Endocarditis in the Current Era*

Computed tomography (CT) scan is indicated to evaluate the lung parenchyma and vasculature. Due to the difficulty in diagnosing septic pulmonary emboli, we obtain chest CT scan routinely as this may change the timing of intervention. Other relevant tests depend on presence of other systemic manifestations of infection/ embolization may include other cross-sectional imaging, brain imaging etc.

It is important to know that it is difficult to apply the Duke's criteria [26] to diagnose TVE due to: (1) the unique anatomy of the structures in the right side of the heart which could simulate vegetations, (2) embolization if occurred is pulmonary rather than systemic which is difficult to diagnose until it evolves into pulmonary infarcts or abscesses, and (3) many of the radiologic findings can be mistaken for pneumonia.

In general, right-sided endocarditis resolves with medical treatment in the

Although antibiotics remained the first line treatment for TVE, several patients may fail this line of therapy and require surgical interventions. In addition, those who have residual TV regurgitation will need either early or late recon-

The following constitutes reasonable indications for surgical intervention [27]:

2.Persistent bacteremia/sepsis (> 7 days) with poor response to antibiotics which sometimes occurs in the presence of a highly virulent bacteria (*Staphylococcus aureus*, and Pseudomonas bacteremia), and infection with organisms that are

1.Right heart failure secondary to severe tricuspid regurgitation with poor

3.Recurrent septic pulmonary embolism with or without right heart failure.

While the exact timing of surgery remains unclear in many of these scenarios, it should be a team approach in decision with input from the cardiologist, cardiac surgeon, and the infectious disease specialist. In absence of urgent/emergent surgical indications (persistent sepsis, recurrent septic embolization, and heart failure), surgery is usually done on elective basis after a good duration of antibiotic therapy and appearance of negative blood cultures. This increases the chance of successful valve repair and minimize risk of recurrent infection. Decision is a bit

4.Large TV vegetations (>20 mm) with or without right heart failure.

5.Abscess (more common in the presence of a prosthesis)

more complicated in IVDA and in those with recurrent endocarditis.

*DOI: http://dx.doi.org/10.5772/intechopen.95365*

**9. Treatment**

• *Medical Treatment*

• *Surgical Treatment*

majority of cases (70–85%).

struction or replacement of the TV.

response to medical therapy.

○ Timing of Surgery

difficult to eradicate such as fungi.

○ Indications for Surgical Intervention

Computed tomography (CT) scan is indicated to evaluate the lung parenchyma and vasculature. Due to the difficulty in diagnosing septic pulmonary emboli, we obtain chest CT scan routinely as this may change the timing of intervention. Other relevant tests depend on presence of other systemic manifestations of infection/ embolization may include other cross-sectional imaging, brain imaging etc.

It is important to know that it is difficult to apply the Duke's criteria [26] to diagnose TVE due to: (1) the unique anatomy of the structures in the right side of the heart which could simulate vegetations, (2) embolization if occurred is pulmonary rather than systemic which is difficult to diagnose until it evolves into pulmonary infarcts or abscesses, and (3) many of the radiologic findings can be mistaken for pneumonia.
