Trivalvular/bivalvular heart: a philosophical, scientific and therapeutic concept

In 1967, following the replacement of infected tricuspid valves in drug addicts with incurable endocarditis, all patients died. The study aim was to determine if tricuspid valve removal, rather than replacement, might offer these patients an improved outcome.

Since July 1970, we have operated on 55 patients with intractable right-sided endocarditis. Before surgery, all had a history of intravenous drug abuse (IVDA) (duration range: 2-20 years; 5 years in 38 cases). In 53 patients the tricuspid valve was excised without replacement; the pulmonary valve was also removed in two cases.

Six (11%) patients died within six weeks of surgery, and 11 died between six months and 24.5 years. Ten of the late deaths were related to IVDA. Among 49 patients who survived surgery for six months to 29 years, 24 (50%) returned to the use of illicit drugs. Only six patients eventually required insertion of a heart valve prosthesis; of these, four died, two due to repeat IVDA. Of 38 long-term survivors (range: 9-29 years), two have a non-functioning bioprosthesis in the tricuspid position, 35 have a trivalvular heart, and one has a bivalvular heart. Only three patients required diuretics and digitalis.

IVDA patients with intractable right-sided infective endocarditis have the best chance of cure and long-term survival by undergoing tricuspid or tricuspid and pulmonary valve excision(s), without prosthetic replacement. No published evidence or long-term follow up data indicate better surgical treatment for this patient group. In this day and age of cost containment, these operations are economical. Operations that work well in non-addicted patients become costly and invariably are associated with a second endocarditis and death in inveterate IVDA cases.