○ **Concomitant Pulmonary Emboli**

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 technique [38].

### ○ **Recurrent Endocarditis**

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

output syndrome, renal failure, and stroke [41]. A debate continues regarding offering IVDA patients and those who are noncompliant, repeat surgery when infection recurs.

### **10. Prognosis**

The majority of TVE respond to medical therapy but is associated with higher risk of recurrence, specifically in IVDA.

The overall prognosis of isolated TV endocarditis is better than left-sided and multivalvular infection. This may be due to younger age of patients, less occurrence of systemic embolization or development of drug-resistance, in addition to the fewer significant hemodynamic derangements that may occur from tricuspid regurgitation in contrast to aortic and/or mitral involvement.

The following have been associated with poor prognosis according to several reports: (1) persistent sepsis with failure to respond to medical therapy, (2) development of right heart failure, (3) fungal infection, (4) recurrent pulmonary embolization, (5) septic shock, and (6) multivalvular involvement.

#### **11. Surgical outcomes**

The estimated operative mortality for surgery for TVE is between 6 and 10% [42]. Excision of the TV has been associated with high morbidity due to right heart failure [43], and TV replacement has been associated with increased risk of recurrent infection and need for permanent pacemaker.

Yanagawa and colleagues reported the outcome sin 1165 patients who underwent surgery for TVE. The indications were recurrent pulmonary embolization, right heart failure, persistent sepsis and concomitant left-sided infection. TV repair was possible in 2/3 of these patients and the majority underwent TV replacement with a bioprosthesis. The authors concluded that both TV repair and replacement have good long-term survival, but repair is associated with less risk of need for pacemaker, recurrence of infection and reoperation [44].

Di Mauro et al. reported the surgical outcomes of isolated TVE in 157 patients (IVDA was present in 38%) of a multicenter registry. Repair was performed in 49%, while replacement with a bioprosthesis was the main procedure in 46% and a mechanical prosthesis was used in 5%. Early mortality was 11% with no difference between repair or replacement. The authors identified the following factors as predictors of poor outcomes: older age, IVDA, fungal endocarditis, repeat operation, the use of a prosthesis, and the presence of intracardiac devices [45].

In a recent systemic review and metanalysis of 752 patients with TVE by Luc and colleagues, tricuspid valvectomy was performed in 14%, while 86% underwent TV replacement. There was more prolonged duration of mechanical ventilation in the valvectomy group, but there was no significant difference in early mortality, right heart failure and recurrence of endocarditis between the two groups. The authors concluded that tricuspid valvectomy is an acceptable initial therapy in those with IVDA to help identify those who will self-select as candidates for later valve replacement [46].

#### **12. Conclusions**

TVE has several features that are unique in comparison to left-sided infection. These include the different population demographics, etiology of infection,

**169**

**Author details**

specifically IVDA.

Sameh M. Said

Division of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: ssaid@umn.edu

provided the original work is properly cited.

*Surgery for Tricuspid Valve Endocarditis in the Current Era*

response to medical therapy and prognosis. High index of suspicion and use of appropriate imaging modalities facilitate early diagnosis and early initiation of appropriate therapy. Surgery remains indicated in those with failure to respond to medical therapy and in the presence of complications. The same principle of surgery for endocarditis apply which are adequate and thorough debridement of all infected materials and excision of all vegetations. Extraction of all associated infected cardiac devices is critical to ensure complete eradication of all sources of infection. Excision of the TV is associated with higher morbidity due to ongoing right heart failure, and TV repair is preferred over replacement if feasible. Debate remains ongoing in regard to offering surgery for those with recurrent infection and

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

#### *Surgery for Tricuspid Valve Endocarditis in the Current Era DOI: http://dx.doi.org/10.5772/intechopen.95365*

*Advanced Concepts in Endocarditis - 2021*

risk of recurrence, specifically in IVDA.

regurgitation in contrast to aortic and/or mitral involvement.

rent infection and need for permanent pacemaker.

maker, recurrence of infection and reoperation [44].

embolization, (5) septic shock, and (6) multivalvular involvement.

infection recurs.

**10. Prognosis**

**11. Surgical outcomes**

output syndrome, renal failure, and stroke [41]. A debate continues regarding offering IVDA patients and those who are noncompliant, repeat surgery when

The majority of TVE respond to medical therapy but is associated with higher

The overall prognosis of isolated TV endocarditis is better than left-sided and multivalvular infection. This may be due to younger age of patients, less occurrence of systemic embolization or development of drug-resistance, in addition to the fewer significant hemodynamic derangements that may occur from tricuspid

The following have been associated with poor prognosis according to several

The estimated operative mortality for surgery for TVE is between 6 and 10% [42]. Excision of the TV has been associated with high morbidity due to right heart failure [43], and TV replacement has been associated with increased risk of recur-

Yanagawa and colleagues reported the outcome sin 1165 patients who underwent

Di Mauro et al. reported the surgical outcomes of isolated TVE in 157 patients (IVDA was present in 38%) of a multicenter registry. Repair was performed in 49%, while replacement with a bioprosthesis was the main procedure in 46% and a mechanical prosthesis was used in 5%. Early mortality was 11% with no difference between repair or replacement. The authors identified the following factors as predictors of poor outcomes: older age, IVDA, fungal endocarditis, repeat operation,

In a recent systemic review and metanalysis of 752 patients with TVE by Luc and colleagues, tricuspid valvectomy was performed in 14%, while 86% underwent TV replacement. There was more prolonged duration of mechanical ventilation in the valvectomy group, but there was no significant difference in early mortality, right heart failure and recurrence of endocarditis between the two groups. The authors concluded that tricuspid valvectomy is an acceptable initial therapy in those with IVDA to help identify those who will self-select as candidates for later valve replacement [46].

TVE has several features that are unique in comparison to left-sided infection. These include the different population demographics, etiology of infection,

the use of a prosthesis, and the presence of intracardiac devices [45].

surgery for TVE. The indications were recurrent pulmonary embolization, right heart failure, persistent sepsis and concomitant left-sided infection. TV repair was possible in 2/3 of these patients and the majority underwent TV replacement with a bioprosthesis. The authors concluded that both TV repair and replacement have good long-term survival, but repair is associated with less risk of need for pace-

reports: (1) persistent sepsis with failure to respond to medical therapy, (2) development of right heart failure, (3) fungal infection, (4) recurrent pulmonary

**168**

**12. Conclusions**

response to medical therapy and prognosis. High index of suspicion and use of appropriate imaging modalities facilitate early diagnosis and early initiation of appropriate therapy. Surgery remains indicated in those with failure to respond to medical therapy and in the presence of complications. The same principle of surgery for endocarditis apply which are adequate and thorough debridement of all infected materials and excision of all vegetations. Extraction of all associated infected cardiac devices is critical to ensure complete eradication of all sources of infection. Excision of the TV is associated with higher morbidity due to ongoing right heart failure, and TV repair is preferred over replacement if feasible. Debate remains ongoing in regard to offering surgery for those with recurrent infection and specifically IVDA.
