UOTW #87

A 23-year-old female presents with shortness of breath. She has a past medical history significant for opioid use and intravenous drug use. Her vital signs are as follows: T°98F HR 118 (sinus) BP 100/60 RR 24. On examination she has an elevated JVP and is using her accessory muscles to breathe. On auscultation, you hear a high pitched, holosystolic murmur, as well as bibasilar crackles. You are asked to assess her with a bedside echocardiogram that reveals the following:

Answer

 

Tricuspid Valve Endocarditis
The bedside ultrasound images demonstrate a large tricuspid valve vegetation. There was evidence of tricuspid regurgitation as well. The patient deteriorated and required intubation and mechanical ventilation. She required intravenous antibiotics and a tricuspid valvectomy. She was extubated 14 days after initial admission to hospital. Post-operative repeat ultrasound of the heart showed no vegetation and no tricuspid valve present.

  • The vast majority of right-sided infective endocarditis (IE) cases involve the tricuspid valve, and are strongly associated with intravenous drug use (IVDU) 1. Infections resulting from IVDU constitutes approximately 30-40% of all tricuspid valve infective endocarditis cases 1.
  • Overall, the detection rate for vegetations by transthoracic echocardiography (TTE) in patients with a clinical suspicion of endocarditis averages around 50% 2. The diagnostic yield of the technique in the detection of vegetations is influenced by several factors: image quality; echogenicity, and vegetation size; vegetation location; presence of valvular disease or valvular prosthesis; experience and skill of the examiner; and pre-test probability of endocarditis 2.
  • Vegetations are typically attached on the low-pressure side of the valve structure, but may be located anywhere on the components of the valvular and subvalvular apparatus, as well as on the mural endocardium of the cardiac chambers of the ascending aorta 3.
  • The vegetation is the hallmark lesion of IE. Typically, vegetation presents as an oscillating mass attached to a valvular structure, with a motion independent to that of the valve 3
  • The sensitivity of TTE for the diagnosis of vegetations is about 75%. Transesophageal echocardiography (TEE) enhances the sensitivity of TTE to about 85-90% for the diagnosis of vegetations, while more than 90% specificity has been reported for TTE and TEE.3
  • Patients with IVDU infective endocarditis have been reported to have a 10-fold higher risk of death or reoperation following surgical therapy compared to those without IVDU.
  • Tricuspid valvectomy is a proposed treatment for IVDU infective endocarditis. There was no difference in 30-day post-operative mortality, heart failure, and stroke in valvectomy patients5

Authors: Sameer Sharif MD FRCPC DRCPSC, Faizan Amin MD FRCPC
Peer reviewer: Ben Smith, MD, FACEP

References

  1. Hussain ST, Witten J, Shrestha NK, Blackstone EH, Pettersson GB. Tricuspid valve endocarditis. Annals of cardiothoracic surgery. 2017; 6(3):255-261. [pubmed]
  2. Evangelista A, Gonzalez-Alujas MT. Echocardiography in infective endocarditis. Heart (British Cardiac Society). 2004; 90(6):614-7. [pubmed]
  3. Habib G, Badano L, Tribouilloy C, et al. Recommendations for the practice of echocardiography in infective endocarditis. European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology. 2010; 11(2):202-19. [pubmed]
  4. Shrestha NK, Jue J, Hussain ST, et al. Injection Drug Use and Outcomes After Surgical Intervention for Infective Endocarditis. The Annals of thoracic surgery. 2015; 100(3):875-82. [pubmed]
  5. Luc JGY, Choi JH, Kodia K, et al. Valvectomy versus replacement for the surgical treatment of infective tricuspid valve endocarditis: a systematic review and meta-analysis. Annals of cardiothoracic surgery. 2019; 8(6):610-620. [pubmed]

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