**2.2 Cardiac implantable device endocarditis**

Cardiac implantable device endocarditis (CIDE) involves cardiovascular implantable electronic devices (CIED) which include permanent pacemakers (PPM), implantable cardiac defibrillators (ICD), and cardiac resynchronization systems (CRT). CIDE is diagnosed based on the presence of the following four criteria:

• Presence of a cardiac device;

*Advanced Concepts in Endocarditis - 2021*

limited experience and long-term data [21].

*2.1.5 Percutaneous options for valve replacement*

complications [19].

replacement is warfarin. Warfarin is can be difficult to manage as levels are dependent on patients' variable vitamin K intake and requires frequent monitoring. Furthermore, problems with compliance with monitoring and anticoagulation therapy is more frequently seen in patients with IVDU and this population is also the most common to present with recurrent right-sided endocarditis and require surgery for valve replacement. With bioprosthetic valve replacement, only first three months of anticoagulation after replacement are required to prevent thrombosis, although this practice itself can be variable [17, 18]. This time frame allows for reendothelialization to the suture zone [17]. Due to decreased duration of anticoagulation, bioprosthetic valves are associated with lower rates of bleeding

Another advantage of bioprosthetic valve replacement compared to mechanical valve, is the thrombosis risk. Obstruction of the tricuspid mechanical prosthesis due to thrombosis is 20 times more frequent than left-sided prosthetic valve thrombosis [17]. This is likely due to low flow state of the right heart compared to the left. Lastly, Patients with bioprosthetic valve replacement are still candidates for pacemaker and ICD placement as compared to mechanical valves [6]. Similarly, embolic events are more common with mechanical valves [19]. Ergo, prosthetic valve replacement may be a better option from this perspective. Mechanical tricuspid valve replacement may be beneficial from the durability perspective as they last longer than bioprosthetic valves [6, 19]. Previously average failure time for tricuspid bioprosthetic valve was 7 years [19]. However, the durability of new bioprosthetic valves have improved over the years as recent data suggest no difference in long term data between bioprosthetic and mechanical valves at 15 years [20]. Additionally, mitral homografts have been used in the tricuspid space but with

Percutaneous tricuspid valve replacement (PTVR) creates unique challenges as compared to the left side. One, the tricuspid annulus is large is size compared to the mitral annulus and can be further increased with right ventricular dilation. For large valve replacement, large caliber sheaths and large bore venous access must be obtained [22]. Only jugular and femoral veins can accommodate such large bores of up to 45 French [22]. Trans-atrial approach has been used in the past; however, this requires surgical expertise. Two, tricuspid valves are more difficult to anchor percutaneously as there is limited calcification and the structure itself is dynamic (changes in diameter in systole and diastole). Three, PTVR carries an increased risk post-procedural conduction defects just as with surgical repair [6, 21]. Frequently with percutaneous replacement the tricuspid annulus becomes stretched. This can cause a complete atrio-ventricular (AV) block, requiring pacemaker placement, due to proximity of the AV node and the bundle of His to the tricuspid valve. Similarly, proximity of the tricuspid valve to the right coronary artery, coronary sinus, vena cava create additional challenges with percutaneous placement and valve design [22]. Furthermore, patients with pacemaker or ICD devices are not great candidates for percutaneous tricuspid valve replacement as placement of a valve may dislodge leads. Lastly, there is very limited data on the percutaneously placed tricuspid valve replacement durability and more studies are necessary. Unlike, for surgical tricuspid valve replacement there are no guidelines regarding timing of percutaneous valve aortic valve replacement after infective endocarditis. Without surgical debridement or percutaneous debulking and with antibiotics use alone, there is a high theoretical reinfection risk of the new tricuspid valve placed using a percuta-

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neous approach after endocarditis.


Specifically, for CIDE diagnosis, the Duke criteria should be used. Patient presentation can be variable and can involve all or just a few symptom including fevers, rigors, anorexia, fatigue, local tissue inflammation. In addition, there may be possible purulent discharge, device exposure, focal pain that may help localize the primary site of infection. Other symptoms could be neurologic or cardiac consistent with embolic stroke, or symptoms of volume overload [23].
