Tricuspid valve surgery in implantable cardiac electronic device-related endocarditis: Repair or replace?

Abstract

Background: The aim of this study was to investigate lead endocarditis-related tricuspid valve regurgitation, to identify underlying causes, and to report our surgical approaches to tricuspid valve endocarditis.

Methods: Between March 2010 and August 2016, medical records of a total of 43 patients (23 males, 20 females; mean age: 63.2±13.6 years; range 48 to 72 years) who underwent tricuspid valve surgery for severe tricuspid regurgitation caused by lead endocarditis, which was previously placed as an implantable cardiac electronic device were reviewed. We removed all systems including infected leads and generators, revised infected wounds and tissues, performed tricuspid valve surgery for lead endocarditis, and applied long-term intravenous antibiotic regimen for the culprit agent, as confirmed by the culture.

Results: Of 43 patients, 18 underwent tricuspid valve repair and 25 underwent tricuspid valve replacement for lead endocarditisrelated severe tricuspid valve regurgitation. During followup (range, 2 to 62 months), two patients required temporary mechanical support due to postoperative acute right heart failure, while eight patients died due to sepsis (n=6; 14%) and stroke (n=2; 4.6%) in the early postoperative period. The remaining patients showed significant improvement in signs and symptoms of heart failure.

Conclusion: Our study results suggest that incompetent experience and inaccurate decision for valve repair may result in delayed valve replacement and prolonged operation time.

Keywords: Implantable cardioverter defibrillator; lead endocarditis; permanent pacemaker; tricuspid valve surgery.

Figure 1. Flow chart of study. CIED: Cardiac implantable electronic device; ICD: Internal cardioverter defibrillator; PPM: permanent pacemaker; LE: Lead endocarditis; TVS: Tricuspid valve surgery; ICU: Intensive care unit

Figure 2. Preoperative echocardiogram showing severe tricuspid regurgitation. (a) Apical two-chamber view and with color Doppler showing pacemaker lead, vegetation around, and severe tricuspid regurgitation. (b) T hree dimension real-time echocardiogram showing infected pacemaker lead and vegetation in the right chamber (white arrow). (c) An intraoperative image of lead vegetation inside right atrium (white arrows).

Figure 3. Intraoperative images. (a) Infected lead and the wires (white arrow) were extracted and removed. (b) Septal leaflet of tricuspid valve was repaired with glutaraldehyde-treated pericar- dial patch after wide quadrangular leaflet resection. (c) Tricus- pid valve replacement with a biological valve. (d) New perma- nent epicardial lead (Medtronic CapSure Epi 10366 and 4968, Medtronic, Inc., Minneapolis, MN, USA) was implanted.