Dawood Murtaza Y, Cheema Faisal H, Ghoreishi Mehrdad, Foster Nathaniel W, Villanueva Robert M, Salenger Rawn, Griffith Bartley P, Gammie James S
Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2015 Feb;99(2):539-46. doi: 10.1016/j.athoracsur.2014.08.069. Epub 2014 Dec 17.
Tricuspid valve infective endocarditis (TVIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. We report our operative single-center experience.
We retrospectively reviewed 56 patients who underwent operations for TVIE between January 2002 and December 2012.
Methicillin-resistant Staphylococcus aureus was present in 41% of patients, septic pulmonary emboli in 63%, moderate/severe tricuspid regurgitation in 66%, and 86% were intravenous drug abusers. Patients underwent early operation if there was concomitant left-sided endocarditis with indications for operation (n = 18), atrial septal defect (n = 6), infected pacemaker lead (n = 4), or prosthetic TVIE (n = 1). The remaining 27 patients were treated with intravenous antibiotics. Five patients completed a 6-week course of intravenous antibiotics before requiring an operation for symptomatic severe tricuspid regurgitation or persistent bacteremia. Twenty-two patients did not complete the antibiotic therapy and underwent operation for symptomatic severe tricuspid regurgitation (n = 15), persistent fevers/bacteremia (n = 3), or patient-specific factors (n = 4). Valve repair was successful in 57% of patients. Overall operative mortality was 7.1%. No operative deaths occurred in patients with isolated native TVIE. Recurrent TVIE was diagnosed in 21% (5 of 24) of the replacement group and in 0% (0 of 32) in the repair group. Use of repair was strongly protective against recurrent TVIE (p < 0.01).
In contrast to previously published reports of high operative mortality with TVIE, this experience demonstrates improved outcomes with low morbidity and mortality, particularly for native isolated TVIE. Future prospective comparisons between surgically and medically treated patients may help to further define indications and timing for operation for patients with TVIE.
三尖瓣感染性心内膜炎（TVIE）并不常见。传统上，患者仅接受抗生素治疗，手术指征尚不明确。我们报告我们单中心的手术经验。
我们回顾性分析了2002年1月至2012年12月期间接受TVIE手术的56例患者。
41%的患者存在耐甲氧西林金黄色葡萄球菌，63%有脓毒性肺栓塞，66%有中度/重度三尖瓣反流，86%为静脉药物滥用者。如果患者伴有有手术指征的左侧心内膜炎（n = 18）、房间隔缺损（n = 6）、感染的起搏器导线（n = 4）或人工瓣膜TVIE（n = 1），则接受早期手术。其余27例患者接受静脉抗生素治疗。5例患者在因有症状的严重三尖瓣反流或持续性菌血症需要手术前完成了为期6周的静脉抗生素治疗。22例患者未完成抗生素治疗，因有症状的严重三尖瓣反流（n = 15）、持续性发热/菌血症（n = 3）或患者个体因素（n = 4）而接受手术。57%的患者瓣膜修复成功。总体手术死亡率为7.1%。孤立性原发性TVIE患者无手术死亡。置换组21%（24例中的5例）诊断为复发性TVIE，修复组为0%（32例中的0例）。采用修复术对复发性TVIE有很强的预防作用（p < 0.01）。
与先前发表的TVIE手术死亡率高的报告相反，本经验显示出低发病率和死亡率的更好结果，特别是对于原发性孤立性TVIE。未来对手术治疗和药物治疗患者进行前瞻性比较可能有助于进一步明确TVIE患者的手术指征和时机。
