- Tricuspid valve endocarditis is managed either surgically or percutaneously depending on factors like resistant infection, recurrent infection showers, or resistant heart failure. - Surgical options include excision with bicuspidization or patch repair, while percutaneous options include aspiration of vegetations using the AngioVac system or the newer Flow Triever system. - The AngioVac system uses a self-expanding nitinol funnel tip and cardiopulmonary bypass to aspirate vegetations, showing technical success in 90% of cases and resolution of bacteremia in 75% within 48 hours.

1. Tricuspid valve endocarditis
Management options
Ahmed Elborae, MSc, MD, PhD, MRCP UK (London)
Lecturer of Cardiology, Cairo University

2. Agenda
• Introduction
• When to intervene?
• How?

3. Introduction
• Right-sided IE accounts for 10% of IE cases
• Incidence ↑ x12 folds in the last decade
due to ↑ “IVDA”
• S. aureus is the predominant organism
(60–90% of cases), mostly MRSA
• The usual presentation is multiple septic
pulmonary emboli
• Less commonly present with right HF
“severe TR or obstruction”
• Vegetation length 20 mm and fungal
etiology are the main predictors of
death(~ 7%)
Expectations
Reality

4. Circulation 2022

5. When to intervene?
Resistant infection
Recurrent showers
Resistant HF

6. Challenges…
• High recurrence rate of IE due to continued drug abuse (25%)
• Mechanical prosthesis thrombosis is (x 20 times) left-sided one “Low flow”
• Tricuspid valve replacement usually with bioprosthesis “Durability?”
Shrestha NK, et al.. Ann Thorac Surg. 2015;100:875–882. doi: 10.1016/j.athoracsur.2015.03.019
More conservative approach

7. Surgical repair options
Gottardi R, et al. Midterm follow-up of tricuspid valve reconstruction due to active infective endocarditis. Ann Thorac Surg 2007;84:1943–1948.
Excision+bicuspidization
Excision+patch repair

8. Percutaneous solutions for isolated vegetation?
• Lessen the microbial burden
• Disruption of fibrotic vegetation >
more surface area for antimicrobials
• Decrease the chance of showering
• Improve valve leaflets dynamics (+/-)
Giulio Russo, et al. Challenges and future perspectives of transcatheter tricuspid valve interventions. European journal of heart failure.2021
Remove the nest !
Aspiration vegectomy
x
x

9. AngioVac aspiration system
The third generation: Self-expanding nitinol funnel-shaped tip
( 20 and 180 degree angle)
Veno-venous bypass circuit
Bangalore S, et al. Catheter Cardiovasc Interv. 2021;98: E475–E477
26 F

10. Angio Vac reperfusion options
At (2000-3000) RPM

11. Technical points
SVC
Vegetation
• Angle calculation (TEE) is very important
• Clockwise torque of the AngioVac catheter
produces counterclockwise turn on TEE image
Meyer et al. J A C C : C A S E R E P O R T S , V O L . 1 , N O . 5 , 2 0 1 9
• Technical success reaching 90%
• Resolution of bacteremia within 48
hours in 75 % of cases
• Tricuspid regurgitation was stationary in
60%, improved in 20%, and worsened in
20%

12. TV IE Angio Vac Case
Stoker et al. Cardiovascular Imaging Case Reports-2022

13. Flow Triever system (Inari)
• Less invasive
• Does not require cardiopulmonary
bypass
• The curved catheter has an
adjustable tip capable of 260
angulation
Almanfi et al. JACC case reports. Vol.4 no 18. 2022

14. Percutaneous solutions for regurge?
Giulio Russo, et al. Challenges and future perspectives of transcatheter tricuspid valve interventions. European journal of heart failure.2021
Future options

15. Take home message
When?
Surgical options
Percutaneous solutions
Resistant
How?
MDT
Psychiatry

16. Thank You !