○ *Tricuspid Valvectomy*

Excision of the TV has been proposed for those with massive valvular destruction and concerns with compliance to therapy, continued IVDA, and increased risk with repeat operations for infected prosthetic TV [28]. In the presence of low-normal pulmonary vascular resistance, this option may work as a temporary measure till sepsis is controlled.

The downside of this approach is right heart failure with development of ascites, peripheral edema and low cardiac output and this should be considered as a bridge for valve replacement once infection is cleared.

○ *Tricuspid Valve Repair*

TV repair should be strongly considered especially in IVDA cases to minimize the use of prosthetic materials and prosthesis that can lead to recurrent infection. The technique of valve reconstruction depends on the degree of valvular destruction:

1.**Direct Suturing:** suitable for small defects that is limited to one or two leaflets.

#### **Figure 3.**

*Intraoperative photo showing a large, excised vegetation from the posterior leaflet of the tricuspid valve. This was performed in a 16-year-old who presented with isolated tricuspid valve endocarditis secondary to intravenous drug abuse and underwent successful tricuspid valve repair after excision of the vegetations.*

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**Figure 5.**

**Figure 4.**

*the tricuspid annulus in this area.*

*Surgery for Tricuspid Valve Endocarditis in the Current Era*

2.**Patch Repair** (**Figure 4**): our preference has been to use autologous pericardium or bovine pericardium to repair larger defects in the leaflet after excision

*Intraoperative photo showing a bovine pericardial patch that is used to augment the septal leaflet of the tricuspid valve and improve coaptation in a patient who presented with severe tricuspid valve regurgitation and history of endocarditis. Notice that augmentation should be done in the belly of the leaflet and not at the* 

3.**Leaflet Replacement:** a complete replacement of one leaflet can be performed using a variety of materials such as autologous or bovine pericardium. Multiple artificial chordae (neo-chordae) may be needed to join the newly formed leaf-

4.**Bicuspidization of the TV:** this is suitable more when infection is localized to the posterior leaflet which can be excised, and both the anterior and septal

5.**Annuloplasty:** annuloplasty maneuvers are needed when the tricuspid annulus is dilated to support the repair and minimize recurrence of regurgitation. This varies from suture annuloplasty (Kay's or De Vega's) to a ring annuloplasty (**Figure 5(A)** and **(B)**). Several studies reported that ring annuloplasty is superior to suture annuloplasty in terms of recurrence of regurgitation [29].

*(A and B). Intraoperative photos showing the technique of tricuspid valve ring annuloplasty. We prefer to use non-pledgeted prolene sutures in a horizontal mattress fashion (A) to secure the ring due to the fragility of the right atrioventricular junction. It is important to secure the ring from the anteroseptal to posteroseptal commissures. The last stitch (pledgeted) is placed within the mouth of the coronary sinus which is critical to reduce the length of the inferior annulus as most of the recurrence of regurgitation occurs due to re-dilation of* 

of the vegetation and debridement of infected tissues.

*free leading edge. Also notice the area of the atrioventricular node (asterisk).*

leaflets are mobilized to form a bicuspid valve.

let with the papillary muscles of the TV and prevent prolapse.

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

#### **Figure 4.**

*Advanced Concepts in Endocarditis - 2021*

○ **Surgical Options**

○ *Tricuspid Valvectomy*

○ *Tricuspid Valve Repair*

till sepsis is controlled.

Other factors that may affect the timing include: (1) the presence of infected intracardiac devices, (2) the causative organism (fungal may not respond to medical

The principles of surgical treatment for isolated TVE follows the same principles

Excision of the TV has been proposed for those with massive valvular destruction and concerns with compliance to therapy, continued IVDA, and increased risk with repeat operations for infected prosthetic TV [28]. In the presence of low-normal pulmonary vascular resistance, this option may work as a temporary measure

The downside of this approach is right heart failure with development of ascites, peripheral edema and low cardiac output and this should be considered as a bridge

TV repair should be strongly considered especially in IVDA cases to minimize the use of prosthetic materials and prosthesis that can lead to recurrent infection. The technique of valve reconstruction depends on the degree of valvular destruction:

1.**Direct Suturing:** suitable for small defects that is limited to one or two leaflets.

*Intraoperative photo showing a large, excised vegetation from the posterior leaflet of the tricuspid valve. This was performed in a 16-year-old who presented with isolated tricuspid valve endocarditis secondary to intravenous drug abuse and underwent successful tricuspid valve repair after excision of the vegetations.*

in endocarditis cases which include thorough debridement, vegetation removal (**Figure 3**), and excision of all infected non-viable tissues. The preference after that will be to minimize the use of prosthetic materials especially in patients with

therapy), and (3) the presence of concomitant left-sided infection.

history of IVDA and to attempt TV repair if possible.

for valve replacement once infection is cleared.

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**Figure 3.**

*Intraoperative photo showing a bovine pericardial patch that is used to augment the septal leaflet of the tricuspid valve and improve coaptation in a patient who presented with severe tricuspid valve regurgitation and history of endocarditis. Notice that augmentation should be done in the belly of the leaflet and not at the free leading edge. Also notice the area of the atrioventricular node (asterisk).*


#### **Figure 5.**

*(A and B). Intraoperative photos showing the technique of tricuspid valve ring annuloplasty. We prefer to use non-pledgeted prolene sutures in a horizontal mattress fashion (A) to secure the ring due to the fragility of the right atrioventricular junction. It is important to secure the ring from the anteroseptal to posteroseptal commissures. The last stitch (pledgeted) is placed within the mouth of the coronary sinus which is critical to reduce the length of the inferior annulus as most of the recurrence of regurgitation occurs due to re-dilation of the tricuspid annulus in this area.*

#### ○ *Tricuspid Valve Replacement*

While TV repair is preferred, TV replacement remains the most commonly performed procedure [30]. Bioprostheses have been the first choice but mechanical prostheses have been also used in these cases. In a study by Cho et al., there was no difference in long-term valve-related complications such as thromboembolic or bleeding events between mechanical and biological prostheses [31].

Total autologous reconstruction of the TV using autologous/bovine pericardium or extracellular matrix reconstruct has been reported in some case reports to avoid the use of the prosthetic materials in the setting of infection [32]. We do not know the long-term outcome of such maneuvers.

• *Special Circumstances*

#### ○ **Isolated TV Vegetations without Valvular Destruction**

In some unique scenarios, large vegetations have been identified on the tricuspid valve without any evidence of valvular destruction or in some patients where the risk of surgery is quite high. Percutaneous aspiration of these large vegetations has been performed as an alternative to surgery [33]. The AngioVac system (AngioDynamics, Latham, NY) was approved in 2014 by the US Food and Drug Administration for removal of intravascular materials such as thrombi and emboli.

This system consists of two percutaneous venous cannulae (reinfusing/drainage) that are connected to an extracorporeal circuit pump head and bubble trap. Thrombotic materials/vegetations are aspirated when the pump is started and then the blood is circulated through a filter prior to returning to the patient. In a study by George et al., the authors reported the outcomes of percutaneous aspiration in 33 patients with large vegetations. Most of these patients (91%) were discharged home with reduced vegetations size in two-thirds [34]. This seems to be a reasonable option especially in those with prohibitive risk of surgery and in those with recurrent infection especially IVDA.

The obvious risks associated with percutaneous aspiration includes pulmonary embolization and vascular access complications.

#### ○ **Prosthetic Tricuspid Valve Endocarditis**

In the presence of TV prosthesis, infection will be difficult to eradicate without removal of the prosthesis. This subgroup of patients may require early and aggressive surgical eradication of infection to minimize in-hospital mortality and morbidities. There is a higher risk of heart block in this subgroup of patients.

#### ○ **Management of Implantable Cardiac Devices/Indwelling Catheters**

All infected leads and devices have to be removed. Hospital mortality is less when infected devices are identified earlier and removed promptly. Extraction of these devices by interventional cardiologist/electrophysiologist is preferred if possible, over the surgical extraction due to higher success and lower complication rates. One option, in less severe cases, is to remove these infected leads/devices, use temporary leads for pacemaker-dependent patients and continue antibiotic therapy and reevaluate the TV later, if repair or replacement is needed.

In severe cases that require urgent surgery, TV repair/replacement with concomitant extraction of the infected leads/devices is a better approach. Temporary

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technique [38].

○ **Recurrent Endocarditis**

*Surgery for Tricuspid Valve Endocarditis in the Current Era*

pacemaker leads can be used with subsequent endovenous implantation of a new

Other options for pacemaker-dependent patients is to use leadless pacemakers or trans-coronary sinus approach to avoid placing the lead through a freshly repaired TV or replaced tricuspid prosthesis. We have used epicardial permanent pacemaker

This is a team decision that should be discussed thoroughly between the electro-

permanent system once infection is cleared is a reasonable approach.

physiologist, cardiologists, cardiac surgeon, and the patient.

combined right and left-sided endocarditis [35].

occurs which can lead to catastrophic hemoptysis.

○ **Concomitant Pulmonary Emboli**

○ **Mycotic Aneurysms**

system as well in some of these complex cases with limited vascular access.

○ **Concomitant Left Sided Disease (Multi-valvular Endocarditis)**

Those with left sided involvement have worse outcomes in comparison with isolated TVE. These patients will require early surgical intervention to decrease mortality and improve outcomes. In a study by Musci and colleagues, 30-day survival was 96.2% for isolated right sided involvement in comparison to 72% for

Mycotic aneurysms involving the pulmonary vasculature are less common and small number of cases have been reported in the literature [36]. Staphylococcus and streptococcus species are the most common organisms involved in developing these aneurysms, but it can also occur in the settings of mycobacterial or fungal infections. Clinical manifestations are usually related to the underlying endocarditis and manifestations specific to these mycotic aneurysms are rare except when rupture

Computed tomography scan is the most reliable for detection of these aneurysms. Due to the high mortality associated with rupture of these aneurysms, transcatheter embolization is recommended, although successful antibiotic therapy

In patients with TV endocarditis and large vegetations, the search for evidence of pulmonary embolization is necessary especially in the presence of hemodynamic instability or acute new pulmonary manifestations. Concomitant pulmonary embolectomy at the time of TV surgery may be considered in patients with large bilateral/unilateral emboli especially if they are accessible. We have performed a retrograde pulmonary embolectomy in a recent case of TVE in an IVDA with CT evidence of bilateral pulmonary septic emboli. This technique is valuable in the presence of emboli in the distal pulmonary arterial bed that may not be accessible with the traditional pulmonary embolectomy

The highest risk of recurrence occurs among those with IVDA [39]. In a study by Huang and colleagues, the authors followed 87 patients who survived their first episode of endocarditis and up to 25% of these patients experienced recurrence of infection within a year of the first episode [40]. Outcomes of repeat operation in this population has been poor with increased mortality. In another study by Jeganathan and colleagues, 68 patients underwent repeat TV operations with early mortality of 13.2% and higher incidence of postoperative bleeding, low cardiac

have been documented in those with small aneurysms that are stable [37].

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

*Advanced Concepts in Endocarditis - 2021*

prostheses [31].

○ *Tricuspid Valve Replacement*

the long-term outcome of such maneuvers.

• *Special Circumstances*

rent infection especially IVDA.

embolization and vascular access complications.

○ **Prosthetic Tricuspid Valve Endocarditis**

While TV repair is preferred, TV replacement remains the most commonly

mechanical prostheses have been also used in these cases. In a study by Cho et al.,

Total autologous reconstruction of the TV using autologous/bovine pericardium or extracellular matrix reconstruct has been reported in some case reports to avoid the use of the prosthetic materials in the setting of infection [32]. We do not know

In some unique scenarios, large vegetations have been identified on the tricuspid valve without any evidence of valvular destruction or in some patients where the risk of surgery is quite high. Percutaneous aspiration of these large vegetations has been performed as an alternative to surgery [33]. The AngioVac system (AngioDynamics, Latham, NY) was approved in 2014 by the US Food and Drug Administration for removal of intravascular materials such as thrombi and emboli. This system consists of two percutaneous venous cannulae (reinfusing/drainage) that are connected to an extracorporeal circuit pump head and bubble trap. Thrombotic materials/vegetations are aspirated when the pump is started and then the blood is circulated through a filter prior to returning to the patient. In a study by George et al., the authors reported the outcomes of percutaneous aspiration in 33 patients with large vegetations. Most of these patients (91%) were discharged home with reduced vegetations size in two-thirds [34]. This seems to be a reasonable option especially in those with prohibitive risk of surgery and in those with recur-

The obvious risks associated with percutaneous aspiration includes pulmonary

In the presence of TV prosthesis, infection will be difficult to eradicate without removal of the prosthesis. This subgroup of patients may require early and aggressive surgical eradication of infection to minimize in-hospital mortality and mor-

○ **Management of Implantable Cardiac Devices/Indwelling Catheters**

All infected leads and devices have to be removed. Hospital mortality is less when infected devices are identified earlier and removed promptly. Extraction of these devices by interventional cardiologist/electrophysiologist is preferred if possible, over the surgical extraction due to higher success and lower complication rates. One option, in less severe cases, is to remove these infected leads/devices, use temporary leads for pacemaker-dependent patients and continue antibiotic therapy

In severe cases that require urgent surgery, TV repair/replacement with concomitant extraction of the infected leads/devices is a better approach. Temporary

bidities. There is a higher risk of heart block in this subgroup of patients.

and reevaluate the TV later, if repair or replacement is needed.

performed procedure [30]. Bioprostheses have been the first choice but

there was no difference in long-term valve-related complications such as thromboembolic or bleeding events between mechanical and biological

○ **Isolated TV Vegetations without Valvular Destruction**

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pacemaker leads can be used with subsequent endovenous implantation of a new permanent system once infection is cleared is a reasonable approach.

Other options for pacemaker-dependent patients is to use leadless pacemakers or trans-coronary sinus approach to avoid placing the lead through a freshly repaired TV or replaced tricuspid prosthesis. We have used epicardial permanent pacemaker system as well in some of these complex cases with limited vascular access.

This is a team decision that should be discussed thoroughly between the electrophysiologist, cardiologists, cardiac surgeon, and the patient.
