CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 63 Letter to the Editor Alternative treatment of tricuspid valve vegetations Salvatore Lentini Submitted 11/11/22; accepted 13/12/22 Published online 7/2/23 Cardiovasc J Afr 2023; 34: 63 www.cvja.co.za DOI: 10.5830/CVJA-2022-071 Dear Editor, I read with interest the article of Yan Chen and co-authors: Tricuspid valve vegetation related to leaflet injury: a unique problem of catheter malposition.1 The authors must be commended on the treatment of this particular case and its favourable outcome. They report on the case of a woman with a large tricuspid valve vegetation during infective endocarditis, most probably following trauma caused by malposition of a central venous catheter, inserted to treat myelodysplastic syndrome. The authors treated their patient with a conservative treatment: antibiotic therapy and removal of the central catheter, with the subsequent disappearance of the vegetation. Despite the good outcome of the reported case, some criticism may arise. For this, I would like to add two more points to the discussion: • Infective endocarditis vegetations of the tricuspid valve represent a serious condition that may lead to further complications. Embolisation to the pulmonary vascular tree may have disastrous consequences, leading to a high mortality rate.2 Risk of embolisation, especially with large vegetations, should be not underestimated. For this reason, tricuspid vegetations, especially large ones, should be treated to prevent embolisation. The treatment may be by surgery. • Surgery however is not always the best option. As in the case described by Chen and co-authors, co-morbid conditions, such as myelodysplastic syndrome, and general clinical conditions may prevent this treatment due to high surgical risk. For this reason, alternative approaches may be needed. A percutaneous procedure may be a useful alternative in these cases. The AngioVac System (Angiodynamics, Latham, NY 12110 USA) is a system that has widely been used for removal of thrombus, right heart masses, and also large tricuspid vegetations, using suction filtration and veno-venous bypass.3,4 This alternative percutaneous approach may be useful to reduce the risk of pulmonary embolisation. Further associated antibiotic therapy, either empirical or better guided as per culture sensitivity against the causative organisms, inclusive of the minimum inhibitory concentrations, would play a role in eradicating the infection. In the treatment of these patients, many other considerations have to be taken in account, such as the stability of the patient, right ventricular function and severity of tricuspid regurgitation. All these factors will influence the clinical outcome. Despite promising results of the AngioVac System, further investigations are still needed. The presence of a ring abscess would for example represent a contra-indication for the procedure, and whether this procedure would be useful in patients who already have septic lung emboli is still to be proven. Further investigations are also needed to recommend this procedure in intravenous drug abusers, patients with indwelling catheters, those with intra-cardiac devices and those with congenital heart diseases, or patients with prosthetic tricuspid valve endocarditis who are not suitable for surgery. Once all the above is addressed, then it would be possible to choose the best patients for the procedure, the period of the learning curve and the volume of patients to be done, before the procedure can be deemed an alternative or an ameliorative in those critically ill patients. I again congratulate the authors on their successful case. References 1. Chen Y, Wang H, Mou Y, Hu S. Tricuspid valve vegetation related to leaflet injury: a unique problem of catheter malposition. Cardiovasc J Afr 2020; 31: 217–220. 2. Mohananey D, Mohadjer A, Pettersson G, et al. Association of vegetation size with embolic risk in patients with infective endocarditis: a systematic review and meta-analysis. J Am Med Assoc Intern Med 2018; 178: 502–510 3. Moriarty JM, Rueda V, Liao M, et al. Endovascular removal of thrombus and right heart masses using the AngioVac System: results of 234 patients from the prospective, multicenter registry of AngioVac procedures in detail (RAPID). J Vasc Interv Radiol 2021; 32: 549–557.e3. 4. Judson GL, Mahadevan VS. Valves, Vegetations, and valves. J Invasive Cardiol 2022; 34: E580 The Salam Centre for Cardiac Surgery, Soba Al-Hilla, Khartoum, Sudan Salvatore Lentini, MD, eiko251961@gmail.com
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