CHEST Guidelines-A-30-Year-Old-Woman-With-Tricuspid-Valvectomy-Pres (1)

A-30-Year-Old-Woman-With-Tricuspid-Valvectomy-Pres (1)

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A 30-year-old woman with a history of intravenous heroin use and tricuspid valve methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis presented to the emergency department in shock. She had undergone a tricuspid valvectomy three years prior due to the endocarditis but continued to have episodes of MRSA bacteremia. Upon examination, she was afebrile but tachycardic, hypotensive, and exhibited signs of acute kidney injury. Broad-spectrum antibiotics were administered after obtaining blood cultures, which revealed MRSA. An echocardiogram highlighted severe right ventricular (RV) failure with features like an enlarged, hypokinetic RV and paradoxical septal motion, which are indicative of significant right heart dysfunction.<br /><br />The condition involves right-sided infective endocarditis (RSIE), which represents a minority of infective endocarditis cases and often requires surgical intervention when resistant to antibiotics. The tricuspid valvectomy chosen as an intervention in her case is often preferred in IV drug users due to the high risk of prosthesis reinfection. Despite being successfully practiced since the 1970s, valvectomy without valve replacement in patients, especially with continued IV drug use, can lead to complications such as right heart failure due to chronic volume overload and RV dysfunction.<br /><br />Ultrasonography was used to illustrate these complications, including RV enlargement beyond typical limits, unimpeded flow across the tricuspid annular plane, and indications of volume overload. Long-term impacts of tricuspid valvectomy could include pulmonary hypertension and signs of heart failure, emphasizing the need for further study on outcomes.<br /><br />The case exemplifies the complex management challenges posed by tricuspid valvectomy products of the opioid crisis. Despite the rarity of valvectomy, this kind of surgery may become increasingly common, highlighting a critical area for ongoing clinical research and guidelines development.

Keywords

intravenous heroin use

MRSA infective endocarditis

tricuspid valvectomy

right ventricular failure

acute kidney injury

right-sided infective endocarditis

IV drug users

RV dysfunction

pulmonary hypertension

opioid crisis