What are the consequences and recommended management of a tricuspid valve abscess in right‑sided infective endocarditis?

Tricuspid Valve Abscess in Right-Sided Infective Endocarditis

When a tricuspid valve abscess develops in right-sided infective endocarditis, surgical intervention should be considered for organisms difficult to eradicate (particularly fungi) or persistent bacteremia >7 days despite adequate antimicrobial therapy, persistent vegetations >20mm with recurrent pulmonary emboli, or right heart failure from severe tricuspid regurgitation unresponsive to diuretics. 1

Consequences of Tricuspid Valve Abscess

Immediate Complications

• Persistent infection and bacteremia despite appropriate antibiotic therapy, particularly with S. aureus or P. aeruginosa, which account for the majority of right-sided IE cases 1
• Recurrent septic pulmonary emboli causing chest pain, cough, hemoptysis, and roentgenographic infiltrates in 75-85% of cases 1, 2
• Right heart failure secondary to severe tricuspid regurgitation, though isolated right HF is relatively rare 1
• Locally uncontrolled infection with potential for abscess enlargement, false aneurysm formation, or fistula development 1

Long-Term Sequelae

• Intravascular pulmonary artery abscess from septic emboli, a potentially fatal complication requiring surgical intervention including possible pulmonary artery resection or pneumonectomy 3
• Multiple lung abscesses and infarctions that may persist despite antibiotic therapy 4
• Paradoxical systemic embolization if a patent foramen ovale is present, allowing vegetations to bypass the lungs and cause stroke or other systemic emboli 1, 5

Surgical Indications (Class IIa, Level C)

The European Society of Cardiology recommends considering surgery in these specific scenarios: 1

1. Microorganisms difficult to eradicate (persistent fungi) or bacteremia persisting >7 days (S. aureus, P. aeruginosa) despite adequate antimicrobial therapy
2. Persistent tricuspid valve vegetations >20mm after recurrent pulmonary emboli with or without concomitant right heart failure
3. Right heart failure secondary to severe tricuspid regurgitation with poor response to diuretic therapy

Important Caveat for IV Drug Users

Surgery should generally be avoided in active IV drug users with right-sided IE due to high recurrence rates from continued drug abuse, unless the above criteria are met 1

Surgical Approach for Abscess Management

Primary Objectives

The two primary surgical goals are complete removal of infected tissue and reconstruction of cardiac morphology. 1

Abscess-Specific Techniques

• Small abscesses can be closed directly after complete debridement 1
• Larger abscess cavities should be allowed to drain into the pericardium or circulation rather than being closed 1
• The presence of an abscess is not necessarily a contraindication for valve repair—intraoperative assessment after debridement determines if remaining tissue quality permits durable repair 1

Valve Management Options

Three surgical strategies are commonly employed: 1

1. Valve repair (preferred when possible, avoiding artificial material) using pericardial patches, tricuspid autograft, or flipped-over mitral patches 1
2. Valve replacement (most common approach, typically with bioprosthetic valve) 1
3. Valvectomy (extreme cases only, risk of severe postoperative right HF especially with pulmonary hypertension; valve can be replaced later once infection cleared) 1

Critical Surgical Principles

• Total excision of infected and devitalized tissue is mandatory to avoid paravalvular leaks in complex cases with locally uncontrolled infection 1
• Minimize use of foreign material whenever possible 1
• Intraoperative transesophageal echocardiography determines exact location and extent of infection, guides surgery, and assesses results 1

Medical Management Considerations

Antimicrobial Therapy Duration

• Extended antibiotic courses (≥6 weeks) are required for complicated infections with perivalvular abscess 6
• Persistent bacteremia >7 days despite appropriate antibiotics indicates likely surgical need 1

Monitoring Requirements

• Regular clinical assessment for signs of heart failure, embolic events, or neurological complications 6
• Serial echocardiography to monitor abscess size, vegetation characteristics, and valvular function 6
• Evaluation for paradoxical embolization if systemic emboli occur, requiring assessment for patent foramen ovale 5

Prognostic Implications

• In-hospital mortality for right-sided IE is approximately 7%, significantly lower than left-sided disease 1, 2
• Vegetation length >20mm and fungal etiology are the main predictors of death in right-sided IE 1, 2
• Recurrence risk is high in IV drug users who continue drug abuse, emphasizing need for concurrent addiction management 3