Ann Thorac Surg 2007;84:1949. doi:10.1016/j.athoracsur.2007.05.093
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
James S. Gammie, MD
Division of Cardiac Surgery, University of Maryland Medical Center N4W94, 22 South Green St, Baltimore, MD 21201
(Email: jgammie{at}smail.umaryland.edu).
Gottardi and colleagues [1] are to be congratulated on an outstanding series of tricuspid valve operations for infective endocarditis. The authors have clearly illustrated techniques that allowed repair of 82% of infected tricuspid valves during a 7-year timeframe without perioperative mortality. This group has also demonstrated superior durability of tricuspid valve repair, with all surviving patients free of severe tricuspid regurgitation at mid-term follow-up.
This series is an important contribution to sparse literature addressing the surgical therapy of tricuspid valve infective endocarditis. Right-sided infected endocarditis differs from left-sided disease in several fundamental ways; it is predominantly a disease of intravenous drug users and those with long-term indwelling hardware. In addition, the consequences of endocarditis are better tolerated on the right side than on the left side (ie, embolism is to the lungs rather than systemic, and severe valvular regurgitation is of lesser hemodynamic consequence). The overall in-hospital mortality for left-sided endocarditis is 15% to 20%, whereas it is 0% to 6% for right-sided endocarditis.
There are still remaining unanswered questions. The indications for tricuspid valve surgery for infective endocarditis are not clearly defined. We approach these patients with benign neglect, and we only operate for intractable right-sided heart failure and persistent infection that does not respond to medical therapy. Operations for tricuspid valve disease are uncommon compared with left-sided heart valve operations, and mortality is consistently higher. In The Society of Thoracic Surgeons National Cardiac Database, tricuspid valve procedures make up 7% of all heart valve operations, yet there is an associated unadjusted perioperative mortality of 10%, which is higher than aortic valve replacements (3%) and mitral valve replacements (5%) or repair (1% to 2%). Given the low likelihood of mortality from medical therapy and the risk of operative intervention, a deliberate approach seems justified and explains why the literature describes few patients with tricuspid valve operations for infective endocarditis. We agree with the authors that when an operation is necessary, repair is preferable to replacement, and this is often possible using established techniques.
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- Gottardi R, Bialy J, Devyatko E, et al. Midterm follow-up of tricuspid valve reconstruction due to active infective endocarditis Ann Thorac Surg 2007;84:1943-1949.[Abstract/Free Full Text]
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