Infective Endocarditis of the Tricuspid Valve
Varun Dev2006, Journal of Cardiac Surgery
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AI-generated Abstract
Infective endocarditis (IE) involving the tricuspid valve is rare, predominantly occurring in intravenous drug users (IDU). This case report details a 32-year-old male IDU who presented with septic symptoms and was diagnosed with tricuspid valve infective endocarditis. Surgical intervention included valve-conserving procedures, highlighting the importance of considering infective endocarditis in patients with nonspecific symptoms, especially in IDUs. Postoperative outcomes demonstrated the feasibility of valve repair as an alternative to replacement.
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Indications and results TriCll'lpid valve excision for tneuspid endocarditis in addicts is recommended to avoid early reinfection, continued sepsis, andlate reinfection becauseof the resumption of intravenoll'l drug abuse,Valvectomy is allegedly weD tolerated hemodynamically by some, but it leads to heart failure in at least a third of patients. In our experience in 10 addicts with staphylococcal endocarditis who had failed to respond to antibiotic therapy,tricll'lpid valve replacement aUowed aU 10 to leave the hospitalfree of infection and free of heartfailure. Resumption of drug addictionin three led to septic death, but not necessarily to tricll'lpid reinfection. Two returned to jobs requiring a high level of physical labor and tolerated this without difficulty. We find no need to foDow the practice of tricuspld valve excision for tricll'lpid endocarditis in addicts. Those who refrain from drug abuse are weD served by valve replacement. Those who do not are doomed with or without a tricll'lpid valve.
603
IMAGES IN CARDIAC SURGERY
Infective Endocarditis of
the Tricuspid Valve
Jagdish Butany, M.B.B.S., M.S., F.R.C.P.C.∗ ,§, Varun Dev, B.H.Sc.,∗ Shaun W. Leong,
B.Sc.,∗ Gursharan S. Soor, B.Sc.,∗ Molly Thangaroopan, M.D., F.R.C.S.C.,†
and Michael A. Borger, M.D., F.R.C.S.C.‡
Departments of Pathology, †Cardiology, and ‡Cardiac Surgery, Toronto General
Hospital/University Health Network, Toronto, Canada; §Department of Laboratory Medicine
and Pathobiology, University of Toronto, Toronto, Canada
∗
ABSTRACT Infective endocarditis (IE) usually involves the left-sided valves, and IE involving the tricuspid
valve (TV) is rare, often developing in intravenous drug users (IDU). We present a case of a 32-year-old
male, an intravenous drug abuser (IDA), who presented with nonspecific septic symptoms, and was treated
with TV conserving surgery. Pathological examination confirmed tissue destruction, friable thrombotic vegetations, and microorganisms in the leaflet tissue. doi: 10.1111/j.1540-8191.2006.00313.x (J Card Surg
2006;21:603-604)
CASE REPORT
A 32-year-old male with a history of myocarditis presented with nonspecific symptoms and multiple septic embolic events. Comorbidities included a history of
intravenous/oral drug abuse (crack/oxycodone), a hepatitis C positive status, and a patent foramen ovale
(PFO). Echocardiography revealed large vegetations on
the tricuspid valve (TV) and blood cultures were positive for Staphylococcus aureus. Intraoperative transesophageal echocardiography (TEE) showed severe tricuspid regurgitation with large prolapsing vegetations
(Fig. 1). The TV was repaired and the PFO closed.
The posterior leaflet and the inferior half of the septal
and anterior leaflets were resected. A neo-leaflet was
constructed with autologous pericardium and Gore-tex
sutures implanted as neo-chordae. Postoperative TEE
revealed mild to moderate tricuspid stenosis and regurgitation. The patient is doing well nine months after the
surgery.
(Figs. 2–4), and abundant gram positive microorganisms (cocci) were seen (Figs. 3 and 4). The TV would
have been significantly dysfunctional.
DISCUSSION
We report a case of infective endocarditis (IE) of the
TV in an intravenous drug user (IDU), treated with valve
sparing surgery. The damaged segments of leaflet tissue were excised and the leaflets reconstructed using
autologous pericardium. Chordae tendineae were
fashioned from synthetic suture material (Gore-tex,
Newark, NJ, USA).
PATHOLOGY
The excised tricuspid leaflet segments (1.7 × 0.8 cm,
1.8 × 0.9 cm, and 2.0 × 0.8 cm, with the thickness ranging from 0.4 to 0.6 cm) were thickened and
nodular, with focal calcification. The chordae tendineae
were thickened and fused, and friable vegetations were
present, mainly on the nonflow surfaces of the leaflet
segments. There was evidence of tissue destruction
Address for correspondence: Jagdish Butany, M.B.B.S., M.S.,
F.R.C.P.C., Department of Pathology E4-301, Toronto General Hospital, Toronto, ON, Canada M5G 2C4. Fax: 416 340 4213; e-mail: jagdish.
butany@uhn.on.ca
Figure 1. Transesophageal echocardiogram shows a large
vegetation (white arrow) present on the posterior leaflet of
the TV.
604
BUTANY, ET AL.
TRICUSPID VALVE ENDOCARDITIS
Figure 2. Photomicrograph of the TV leaflet showing extensive tissue damage and elastic tissue disruption. Thrombus is
present on the nonflow surface (arrows), and blood and polymorphonuclear leukocytes were present in the substance of
the leaflet ( ∗ ). The leaflet tissue is markedly thickened (Stain:
Movat Pentachrome, original magnification = 16×).
While 76% of endocarditis cases involving IDU occur on the right side, only 5% to 10% of all endocarditis cases occur on the right.1,2 Streptococcus viridans is the most common cause of IE overall, while
S. aureus is the most common cause of IE in IDU.2-4
Frontera and Gradon hypothesize that IDU patients exhibit a greater expression of matrix molecules that bind
to microbial surface components recognizing adhesive
matrix molecules on the right-sided valvular surface,
predisposing these valves to an increased S. aureus
adherence.2
Our patient presented with septic pulmonary emboli
(resulting from the dislodgment of vegetative material),
and tricuspid regurgitation, which have been found to
be common symptoms among tricuspid valve endocarditis (TVE) patients.1,5 The PFO likely contributed to
higher blood flow and pressures on the right side of the
J CARD SURG
2006;21:603-604
Figure 4. Photomicrograph showing abundant colonies of
gram positive bacteria (arrowhead) in the significantly destroyed tricuspid leaflet tissue (Stain: Gram, original magnification = 200×).
heart, resulting in thickening (fibrosis) and damage to
the TV leaflets and chordae tendineae, further predisposing the TV to IE.
In most cases, TVE can be controlled with antibiotics.1 However, as in our patient, surgery is warranted
in cases with large vegetations, persistent sepsis, and
tissue destruction.1 The patient’s PFO also warranted
surgery. Because of extensive leaflet destruction, TV
replacement may be the procedure of choice in most
surgical centers. However, we strongly believe that TV
replacement is associated with an increased risk of repeat infection, thrombosis, and structural valve failure;
therefore, we avoid this procedure whenever possible.
Our patient underwent a valve conserving and reconstruction procedure,1,6 and is doing well 9 months after
the surgery.
IE must be considered in patients presenting with
nonspecific features of infection. In particular, TVE
must be considered a possibility in an IDU when no
other cause of symptoms is easily found. In many
cases, TV repair is a viable alternative to replacement
with a prosthetic valve.
REFERENCES
Figure 3. Photomicrograph showing significant tissue destruction ( ∗ ), vegetations (arrows), and colonies of gram positive cocci (arrowheads) are seen in the zona spongiosa (Stain:
Movat Pentachrome, original magnification = 25×).
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Am Heart J 1989;117(5):1140-1146.
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3. Netzer RO-M, Zollinger E, Seiler C, et al: Infective endocarditis: Clinical spectrum, presentation and outcome. An
analysis of 212 cases 1980-1995. Heart 2000;84:25-30.
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Robbins SL (ed): Robbins Pathologic Basis of Disease. 6th
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572-576.
5. Yamashita S, Noma K, Kuwata G, et al: Infective endocarditis at the tricuspid valve following central venous catheterization. J Anesth 2005;19:84-87.
6. Hachiro Y, Harada H, Baba T, et al: Concomitant mitral and
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