**9. Treatment**

*Advanced Concepts in Endocarditis - 2021*

has been reported with *Staphylococcus aureus* [23]. When sepsis is uncontrolled, this

*(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.*

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),

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

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

can lead to right heart failure, septic shock, and multiorgan failure.

below (Type II) or both sides (Type III) of the septal leaflet of the TV [25].

**162**

**Figure 2.**

*Right atrium; RV: Right ventricle.*

**8. Diagnosis**

**Figure 1.**

multivalvular involvement.

• *Medical Treatment*

In general, right-sided endocarditis resolves with medical treatment in the majority of cases (70–85%).

• *Surgical Treatment*

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 reconstruction or replacement of the TV.

○ Indications for Surgical Intervention

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

	- Timing of Surgery

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 more complicated in IVDA and in those with recurrent endocarditis.

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