[Tricuspid valvulectomy in antibiotic-refractory right-heart endocarditis]

A 19-year-old man, known to be addicted to intravenous heroin, was admitted because of respiratory failure with a septic fever up to 40.0 degrees C. An abscess at the site of intravenously heroin injection on the right arm had been previously opened. At examination he was pale and his general condition was poor. There were numerous puncture sites over lower arm veins, some of them thrombosed. There were no signs of septic emboli to the skin and to visible mucosae. The spleen was not palpable.

There was leucocytosis with shift to the left, thrombocytopenia (54,000/microliter), anaemia (haemoglobin 7.9 g/dl) and markedly raised C-reactive protein (202 mg/dl). Blood culture grew Staphylococcus aureus. Transthoracic and transoesophageal echocardiography revealed a large vegetation on the tricuspid valve, confirming infectious endocarditis involving the tricuspid valve. Chest radiogram showed an infiltrate and pleural effusion of the left lung.

Infectious emboli to the lung necessitated artificial ventilation. The septic process could not be controlled by antibiotics. The whole of the tricuspid valve was therefore removed, followed by high doses of antibiotics (vancomycine, gentamicine, rifampicine). This successfully controlled the infection and a postoperative sacroileitis. Postoperative echocardiography revealed severe tricuspid regurgitation with marked enlargement of the right ventricle, paradoxical movement of the interventricular septum and a dilated inferior vena cava. 7 months postoperatively there were no clinical signs of severe right heart failure.

Removal of the tricuspid valve without valve replacement can be successfully undertaken to control the infection in intravenously heroin addicts in whom the valve has been destroyed by infectious endocarditis.