The Heart Valve Society

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< > Tricuspid Valve Endocarditis in Intra venous drug user : Complex Surgical Reconstruction
Yasir Ahmed, Chiara Proli, Sobaran S. Sharma, Rhodri Davies, Adrian Ionescu, Pankaj Kumar.
Morriston Hospital, Swansea, United Kingdom.

Patient Demographics: 24 years old female
Relevant History: Long history of intra-venous drug use and was hepatitis C-positive. The patient presented with breathlessness, chest pain and feeling generally unwell (pyrexia, malaise and weight loss). Trans-thoracic echocardiogram showed large highly mobile vegetations on the posterior and anterior leaflet of the tricuspid valve, resulting in free, unrestricted tricuspid regurgitation. CT chest demonstrated multiple pulmonary septic emboli including right lower lobe infarction. The unifying diagnosis was native tricuspid valve endocarditis with S. aureus.
Pre-Operative Plan: The patient received culture-guided intravenous antibiotics, intensive intravenous diuresis therapy as well as nutritional support and counselling. The patient was monitored with serial TTE. Screening tests confirmed no further drug use. Despite the optimal medical management, she continued to have further bouts of sepsis and free tricuspid regurgitation and therefore surgical intervention was recommended.
Discussion of what was actually done and the challenges, deaths and complications encountered. (Unless case is still pending): The patient underwent complex tricuspid valve reconstruction without annuloplasty ring. Intra-operatively, we found large vegetations attached to the posterior leaflet and part of the anterior leaflet of the tricuspid valve. The infected leaflet segments were largely destroyed resulting in a large regurgitant orifice. The whole posterior leaflet and part of the anterior leaflet were resected and all the infected material was debrided. The tricuspid valve was reconstructed with a large pericardial patch with its free edge supported by two artificial PTFE chords. On inspection the leaflet had good mobility and there was minimal regurgitation on testing and therefore a decision was made not to implant an annuloplasty ring. Trans-oesophageal echocardiogram performed at the end of the procedure confirmed residual mild central tricuspid regurgitation (considered acceptable in the clinical setting). She received intravenous antibiotic therapy postoperatively, and her recovery was otherwise unremarkable with no adverse events. Pre and post-operative features of this case and the surgical technique with the echocardiogram and surgical images will be presented.


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