Surgery for Right-Sided Endocarditis: How to Avoid Replacing the Tricuspid Valve

Tricuspid valve infective endocarditis (TVIE) and related surgical interventions are on the rise due to the increase in intravenous drug abuse (IVDA) and the rising prevalence of chronic vascular access and transvenous pacer devices. TVIE typically responds to medical management. Surgery is usually reserved for cases with persistent sepsis, recurrent pulmonary emboli, concomitant left-sided infective endocarditis (LSIE) requiring intervention, or severe tricuspid regurgitation (TR) with heart failure symptoms unresponsive to medical treatment. Isolated TVIE is rarely invasive, and post-repair residual moderate TR is well tolerated and medically manageable, making the tricuspid valve (TV) amenable to repair. In addition, the shorter durability of a bioprosthesis in young patients, the high risk of reinfection of a prosthetic valve with continued IVDA, and the increased need for permanent pacemaker with valve replacement all support valve repair rather than replacement when feasible. Surgical strategy is based on thorough debridement of all infected tissue and rendering the valve as competent as possible. Repair techniques include pericardial (preferably autologous) patch augmentation, ring annuloplasty, and creation of neochordae. Short-term outcomes are good overall and related mainly to associated comorbidities or LSIE, if present. In patients with IVDA, infection recurrence is high, mostly due to relapse of drug abuse, resulting in worse long-term outcomes.