Surgical Treatment Methods for Tricuspid Valve Infective Endocarditis

Introduction: In recent years, there has been a significant increase in the incidence of tricuspid valve infective endocarditis (IE), which is associated with both the increased number of invasive examinations and procedures and the high rates of intravenous drug use. The initial treatment for tricuspid valve IE was surgical removal of the focus of infection and restoration of intracardiac hemodynamics.

Reconstructive surgery aimed at preserving the valve is the preferred method of surgical treatment. If a valve-­preserving operation is not possible due to significant valvular apparatus destruction, implantation of artificial heart valves (both mechanical and biological) is the method of choice.

Objective: To analyze the results of reconstructive valve-­preserving surgery and tricuspid valve replacement for tricuspid valve IE treatment.

Materials and methods: In the Scientific Research Institute – Specialized Cardiac Surgery Clinical Hospital named after Academician B.A. Korolev (Nizhny Novgorod, Russian Federation) 110 patients underwent surgery for tricuspid valve IE. Primary surgery was performed in 97 patients, and 13 patients underwent repeated surgery. The patients were divided into 2 groups based on the chosen surgical method for correcting tricuspid valve disease. Group 1 included 62 patients who successfully underwent tricuspid valve replacement: mechanical prostheses in 10 patients and biological prostheses in 52 patients. Group 2 included 38 patients who underwent reconstructive valve­preserving surgery. All patients underwent De Vega annuloplasty. In 10 patients it was directly associated with bicuspidalization of the tricuspid valve and plastic surgery of intact leaflets. Two patients had suture annuloplasty of the tricuspid valve based on the modified technique. In 2 of 3 patients, an infected right atrial thrombus was removed. Three patients underwent removal of the left ventricular wall abscess and aortic valve replacement for critical stenosis. After translocation of the chords, triangular resection of the anterior leaflet was performed to separate the chord of the left side of the chest and the myxoma of the right and left chest.

Results: In the early postoperative period, no valve­related complications were observed in group 1. The most common nonlethal complication was a third­-degree atrioventricular block. Multiple organ dysfunction syndrome occurred in 3 patients; cardiac tamponade was reported in 2 patients, and 1 patient had postoperative bleeding that required resternotomy for serous mediastinitis in the mid­term period and reosteosynthesis. At the hospital stage, 1 patient from group 1 died, whereas there were no deaths in group 2. In­-hospital mortality in the groups of operated patients was 0.9%.

Functional ultrasound imaging findings in the postoperative period show that patients from group 1 had the peak gradient across the prosthetic tricuspid valve of 9.4 ± 1.8 mm Hg, while the mean gradient was 5.8 ± 1.75 mm Hg. There was a significant decrease in the estimated right ventricle pressure from 54.0 ± 16.2 to 35.0 ± 5.5 mm Hg. In group 2 tricuspid valve regurgitation was not observed in 27 patients, while mild and moderate regurgitation was reported in 8 and 3 patients, respectively. The peak gradient during the tricuspid valve reconstruction was 6.2 ± 1.7 mm Hg, while the mean gradient was 2.8 ± 0.75 mm Hg. The annulus fibrosus size during tricuspid valve annuloplasty averaged 30.8 ± 2.5 (28­33) mm. There was a decrease in the right ventricle pressure from 44.0 ± 18.4 to 32.0 ± 7.3 mm Hg. In the mid-­term follow­up, surviving patients were classified as NYHA classes I­-II. Of 110 patients discharged from the clinic, we were able to trace the fate of 69 patients, which accounted for 62.7%. In the long-­term period, 3 patients from group 1 died. Thus, long­term mortality in the general group was 2.72%.

Conclusions: Reconstructive surgery has significant advantages over tricuspid valve replacement using various artificial heart valve models: lower rates of in-­hospital and long­-term mortality and specific complications, higher quality of life. Compliance with principles and methods of pathogenetic treatment of electrode­induced IE guarantees a success in the cohort of severe patients. The technique of reconstruction and restoration of tricuspid valve structures and functions in case of active tricuspid valve IE with detachment of the chords and destruction of the leaflets demonstrated high surgical efficiency.

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