What is the appropriate management for a patient with severe aortic stenosis and vegetation on the tricuspid valve?

Management of Severe Aortic Stenosis with Tricuspid Valve Vegetation

In patients with severe aortic stenosis and tricuspid valve vegetation, surgical intervention addressing both valves is strongly recommended to reduce mortality and improve quality of life.

Assessment and Diagnosis

• Comprehensive echocardiography is essential to evaluate:

  • Severity of aortic stenosis
  • Size and characteristics of tricuspid valve vegetation
  • Right ventricular size and function
  • Presence of pulmonary hypertension
  • Tricuspid annular diameter (significant dilation considered at ≥40 mm or >21 mm/m²) 1

• Blood cultures should be obtained to identify potential infective organisms if vegetation suggests endocarditis

Management Algorithm

1. Surgical Management (Primary Approach)

• Combined surgical intervention is the preferred approach for patients with severe AS and tricuspid valve vegetation 2, 1

  • Aortic valve replacement (AVR) for the severe AS
  • Tricuspid valve repair or replacement based on vegetation characteristics

• Surgical options for tricuspid valve:

  • Vegetation excision ("vegetectomy") with valve repair if vegetation is well-circumscribed with minimal valve damage 3, 4
  • Tricuspid valve repair with annuloplasty ring (preferred when feasible) 1
  • Tricuspid valve replacement if significant valve deformation or advanced leaflet tethering exists 1
    • Bioprosthetic valves preferred over mechanical valves 1

2. Surgical Risk Stratification

• Low to intermediate surgical risk patients:

  • Combined surgical AVR and tricuspid valve intervention is appropriate 2, 5

• High surgical risk patients:

  • Consider transcatheter aortic valve replacement (TAVR) for aortic stenosis 2
  • Individualized approach for tricuspid valve vegetation based on:
    • Size of vegetation
    • Presence of infection
    • Right ventricular function

3. Contraindications and High-Risk Features

• Absolute contraindications for surgery 1:

  • Severe RV dysfunction with very large annuli and significant leaflet tethering
  • Irreversible liver cirrhosis

• High-risk features 1:

  • Pre-operative TV tethering height >8 mm
  • Irreversible RV dysfunction
  • Advanced pulmonary hypertension

Special Considerations

Asymptomatic Patients

• Even in asymptomatic patients with severe AS, the presence of tricuspid valve vegetation warrants intervention due to:
  • Risk of embolization
  • Potential for rapid clinical deterioration
  • Progressive RV dilatation or deterioration of RV function 1

Patients Requiring Urgent Non-cardiac Surgery

• In patients with severe AS and tricuspid valve vegetation requiring urgent non-cardiac surgery:
  • Definitive intervention (SAVR or TAVR) is appropriate prior to non-cardiac surgery 2
  • Balloon aortic valvuloplasty may be considered as a bridging procedure in select cases 2

Post-Intervention Management

• Antimicrobial therapy if vegetation is due to infective endocarditis
• Regular echocardiographic surveillance to assess:
  • Valve function
  • Right ventricular function
  • Potential recurrence of vegetation 1
• Anticoagulation based on type of valve replacement and presence of other risk factors

Pitfalls and Caveats

1. Delaying surgery in symptomatic severe tricuspid regurgitation with vegetation can lead to irreversible right ventricular damage and poor surgical outcomes 1

2. Underestimating the impact of tricuspid valve disease - Severe TR is a very poor prognostic sign in patients with AS, and the outcome depends on the degree of pulmonary hypertension and right ventricular dysfunction 2

3. Inadequate assessment of vegetation characteristics - Size, mobility, and attachment of vegetation should be carefully evaluated as they influence surgical approach and risk of embolization

4. Failure to treat the tricuspid valve - The tricuspid valve should be treated whenever possible when vegetation is present, as recommended by expert panels 2