Substance use disorder-associated tricuspid endocarditis: Staged surgery from valvectomy to replacement

Optimal surgical treatment of infective tricuspid infective endocarditis (TVIE) is controversial in the setting of active substance use. This study evaluated patients who had endocarditis that was not amenable to tricuspid valve repair. In these patients, a valvectomy was performed to remove the diseased tissue. Patients were then offered a subsequent tricuspid valve replacement after proper follow-up and drug abstinence.

A single-center database was queried (2015-2025) to identify adults who underwent valvectomy for TVIE not amenable to repair after failed medical therapy and persistent positive blood cultures. Patients who underwent valvectomy with documented intravenous drug abstinence for 6 months were considered for staged tricuspid valve replacement (sTVR). Patients with persistent drug use did not receive further surgical treatment. Baseline characteristics, outcomes, and survival were evaluated.

In total, 153 patients underwent surgical treatment for TVIE. Tricuspid valvectomy was required in 51 patients. Of the patients, 66% were female, with a median age of 30 years. There were 2 operative mortalities (3.9%). The 1-, 5-, and 8-year survival was 91%, 62%, and 51%, respectively; 26 (51%) received an sTVR and 25 (49%) did not receive sTVR (non-sTVR). In those that received an sTVR, there were 0 operative mortalities, median postoperative length of stay was 6 days, and median hours in the intensive care unit was 30. Intravenous drug use relapse after sTVR was present in 57.7% of patients. Survival at 1 and 5 years after the sTVR was 100% and 60%.

Tricuspid valvectomy is an acceptable initial treatment in high-risk patients. Tricuspid valve replacement after completing an abstinence program from intravenous drugs for 6 months has acceptable outcomes in a complex patient population. Further study of long-term outcomes is warranted.