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Consequences of total tricuspid valvulectomy without prosthetic replacement in treatment of Pseudomonas endocarditis
Consequences of total tricuspid valvulectomy without prosthetic replacement in treatment of Pseudomonas endocarditis Tricuspid valvulectomy without prosthetic replacement has been advocated as a life-saving measure in the treatment of Pseudomonas endocarditis. The present report describes the clinical, hemodynamic, and anatomic consequences of this new approach in a patient who died in an automobile accident 7 months after total removal of the tricuspid valve.
Erwin Robin, M.D., John Belamaric, M.D., Norman W. Thoms, M.D., Agustin Arbulu, M.D., and Sunilendu N. Ganguly, M.D., Detroit, Mich.
An increase in the frequency of tricuspid valve involvement by Pseudomonas aeruginosa has been reported among persons addicted to drugs.': ~ When this organism becomes resistant to antibiotics, the infection becomes medically intractable and the patient dies of the disease." 4 In order to avert this fatal outcome, five years ago we" introduced a new therapeutic approach consisting of complete removal of the tricuspid valve without prosthetic replacement. Case report A 19-year-old black man, addicted to heroin for 3 years, was admitted because of shortness of breath, chills, fever, and episodes of hemoptysis. There was no history of previous cardiopulmonary disease. The patient appeared to be chronically ill. The blood pressure was 120/85 mm. Hg; pulse From the Departments of Cardiology, Pathology, and Surgery, Hutzel Hospital, Wayne State University, Detroit, Mich. This study was supported by Michigan Heart Association Grant No. 306 705t and Hutzel Hospital Research and Education Fund. Received for publication May 13, 1974. Address for reprints: Erwin Robin, M.D., 100 William Dr., Elgin. 111. 60120.
rate 110 beats per minute and regular; respiratory rate 30 beats per minute, and oral temperature 101 F. The head, eyes, and nose were unremarkable. The jugular and carotid pulsations and the cardiac apical impulse were normal. There was no substernal heave. Heart sounds were of normal intensity. A Grade 2/6 systolic murmur was heard over the fourth and fifth left intercostal spaces close to the sternum; it increased to a Grade 4/6 with deep inspiration. Rhonchi were heard over both lung bases. The liver was palpable 2 em. below the right costal margin. It was neither tender nor pulsatile. The patient did not have ascites or leg edema. On admission, the white blood count was 14,000 per cubic millimeter with 85 per cent neutrophils. Six blood cultures grew Pseudomonas aeruginosa. A chest roentgenogram revealed a normal heart size, left pleural thickening, and bilateral patchy infiltrates. An electrocardiogram was normal. Initially the patient received 30 Gm. of carbenicillin intravenously and 300 mg. of gentamicin intramuscularly per day. After 6 weeks of treatment, he was still febrile and had persistent Pseudomonas septicemia. Carbenicillin was discontinued and intramuscular tobramycin was added in a daily dose of 300 mg. Gentamicin and tobramycin were continued for 3 weeks without improvement. Because of an unrelenting septic course, cardiac 0
461
462
The Journal of Thora cic a nd Card iovascular Surgery
Robin et al.
Fig. I. Dilated , hypertrophied right atrium (RA ) and right ventricle (RV ). The tricuspid leaflets a re absent and the annulus (ar ro w s) is free of bacterial vegetations.
catheterization was performed and a presumptive diagnosis of tricu spid va lvula r endocarditis with mild insufficiency was made . At operation, bacterial vegetations were found on all three leaflets of the tricuspid valve and on the endocardial surface of the right atrial a nd ventricular septa. Debridement of the septal vegetations and total remov al of the tricuspid valve without prosthetic replacement were performed. The right atrium and ventricle were irrigated with a solution containing 20 mg . of gentamicin and 5 Gm. of carbenicillin. Culture of the vegetations was positi ve for Pseudomonas aer u ginosa. After the operation, carbenicillin and tobrarnycin were administered for 4 weeks. The postoperative course was uneventful. Six months after the operation, the patient was readmitted for further evaluation. He was able to carry out his normal daily activities without difficulty. The only significant physical findings were a substern a l heave, distended neck veins, and a puls atile liver which extended 4 em . below the right costal ma rgin. There were no murmurs, ascites, or leg edema. A second cardiac catheterization was performed. One month later, the patient died from head injur ies sustained in an automobile accident. Autopsy. The most significant findings were confined to the heart and liver. There were extensive fibrous pericardial adhesions without compression or kinking of the major veins by the thickened pericardium. With the pericardium removed, the heart weighed 440 grams. The right atrium and the right ventricle were markedly hypertrophied and dilated ( Fig. I) . The diameter
of the right atrium me asured 6.0 em . Its muscular wall was thickened and measured as much as 0.4 em. The pectinate muscles were longer, wider, and thicker than normal and resembled the columnae carnae of the right ventricle. The right ventricular mu scle mass was increased, and the wall of the dilated right ventricle was 0.5 em. thick . The ring of the tricuspid valve was dilated and measured 15.0 em . The tricuspid valve leaflets were completely absent. and a fa int, grayish , linear thickening of the endocardium was present at their former insertion sites. Microscopic examination disclosed severe hypertrophy of myocardial fibers of the right atrium and ventricle (Fig. 2). A circumferential hyalinized scar was present at the tricuspid annulus. Examination of the liver revealed conge stive hepatomegaly ( 1,660 grams) , loss of centrolobular hepatocytes associated with fibrosis in some areas, and fibrosis of portal tracts with fibrous bridging between some of the tracts (Fig. 3). There was no evidence of viral hepatitis, talc crystals, or esophageal varices.
Discussion
Between 1969 and 1972 we have treated 21 heroin addicts with Pseudomonas endocarditis of the tricuspid valve. All were given carbenicillin, gentamicin, polymyxin B, and tobramycin in various dosages and combinations. Six patients were cured and 1 died . Fourteen in whom medical treatment failed were subjected to surgical ther-
Volume 68
Pseudomonas endocarditis
Number 3
463
September, 1974
Fig. 3. Liver with portal and central fibrosis. (Verhoeff-van Gieson; original magnification "125.) Inset: Central vein region. (Original magnification )(150.)
Fig. 2. Marked hypertrophy of myocardial fibers of the right atrium. Inset: Right atrial myocardium of a normal control specimen photographed at the same magnification. (Hematoxylin and eosin; original magnification "300.)
A.
I
r y r T Y
30 20
.
~
15
10
10
5f·-I,r-,j~V"vVVV'1/"11~Vv
5
:I:
E
~
SVC
RA
RV
SVC
RA
RV
Fig. 4. Pressure tracings obtained before (A) and after (B) total tricuspid valvulectomy. There is complete ventricularization of the right atrium (RA) and superior vena cava (SVC). RV, Right ventricle.
apy. In the first 2 patients, the tricuspid valve was removed and replaced by a prosthesis. Both died from persistent Pseudomonas septicemia. In the remaining 12, tricuspid valvulectomy without prosthetic replacement was performed. A bacteriologic cure was obtained in 10 of them, but 2 died from their unremitting infection. In the present case, bacterial involvement of the tricuspid valve was suspected because of fever, leukocytosis, Pseudomonas growth
in blood cultures, diffuse pulmonary infiltrates (septic emboli), and a systolic murmur which increased over the tricuspid area with deep inspiration." Analysis of the right atrial pressure curves obtained prior to the operation revealed normal V waves, which suggested that the degree of tricuspid insufficiency was mild (Fig. 4).' Cardiac surgery has been performed in the treatment of acute endocarditis when medical treatment had failed. B . " However,
The Journal of
464
Robin et al.
Thorocic and Cardiovascular Surgery
Table I. Cardiac hemodynamics before and after total removal of the tricuspid valve Before valvulectamy
After valvulectamy
Parameters
Base line
Exercise *
Base line
Exercise"
SVC (mm. Hg) RA (mm. Hg) IVC (mm. Hg) RV (mm. Hg) PA (mm. Hg) PWP (mm. Hg) Ao (mm. Hg) LV (mm. Hg) HR (beats/min. ) CH (L./min./sq. M.) SI (c.c./beat/sq. M.)
(4)
(4)
(12)
(11 )
(4 )
(4)
(12)
(11 )
(5)
(5)
(13 )
(12)
20/6
21/3
25/7
25/4
20/9 (16)
25/10 (17)
25/10 (15)
23/10 (15)
(6)
(7 )
(7 )
(6)
105/80 (90)
104/78 (92)
110/79 (93)
108/80 (90)
100/8
104/5
110/8
108/5
110
155
109
150
3.3
5.6
3.5
5.2
30
36
32
35
Legend: SVC, Superior vena cava. RA, Right atrium. IVC, Inferior vena cava. RV, Right ventricle. PA, Pulmonary artery. PWP, Pulmonary wedge pressure. Ao, Aorta. LV, Left ventricle. HR, Heart rate. CI, Cardiac index. Sl, Stroke index. "The patients exercised in the supine position on a bicycle ergometer at a work load of 150 Kg.-M. per minute for 3 minutes. tCardiac output was calculated from duplicate standard dye-dilution curves following injection of 5 mg. of indocyanine green into the pulmonary artery and sampling from the aortic root.
until our" initial report, nowhere in the English medical literature could we find any experience with tricuspid valvulectomy without prosthetic replacement in endocarditis. This procedure was selected because of (1) our initial failure to control the infection by removing the tricuspid valve and replacing it with a prosthesis; (2) the high rate of relapse of addiction among our patients, which could lead to infection of a prosthetic device; and (3) reports of long-term survival in patients with severe tricuspid insufficiency.l'"?" Our patient had been unsuccessfully treated for 9 weeks with carbenicillin, gentamicin, and tobramycin. His condition improved dramatically after the infected leaflets and septal vegetations were removed, with a bacteriologic cure achieved within the first postoperative week. At autopsy, there was no evidence of endocarditis (Fig. 1).
Most of the knowledge of the dynamic circulatory changes resulting from isolated tricuspid insufficiency has been derived from animal investigations. Halmagyi and associates-" demonstrated that the characteristic signs of tricuspid insufficiency develop only when at least 2 leaflets were functionally incompetent. Despite a significant increase in the right atrial pressure, as well as gross and microscopic evidence of hepatic congestion, neither heart failure nor ascites occurred. In contrast, Spellman and Balkiscon!" and more recently Michl and assoelates" were able to show that either partial or virtually complete defunctionalization of the tricuspid valve consistently results in ascites. MUller and Shillingford" have reported that in severe tricuspid incompetence the backflow equals or even exceeds the forward cardiac output. Notwithstanding these experimental observations, survival up
Volume 68 Number 3
Pseudomonas endocarditis
465
September, 1974
to 39 years has been reported in patients with isolated severe tricuspid insufficiency who do not have complicating pulmonary or left heart disease.r"> In our patient, the right atrium and ventricle behaved as a common hemodynamic chamber after removal of the tricuspid valve (Fig. 4). Except for the increase in pressure in the right atrium and venae cavae, the hemodynamic data observed 6 months postoperatively were similar to those obtained preoperatively (Table I). Thus, in spite of the overload produced by the regurgitant volume, the right heart was able to maintain a normal pulmonary pressure and flow. An important finding in the liver was the recent loss of hepatocytes, in addition to fibrosis. This suggests a slow, continuous loss of parenchymal tissue. Whether this process will lead to cirrhosis is debatable, especially in view of reports that patients have tolerated severe degrees of tricuspid insufficiency for several decades without evidence of hepatic dysfunction.t'"":' Clinical implications
In bacterial tricuspid valvulitis resistant to medical therapy, total excision of the tricuspid valve without prosthetic valve replacement is a life-saving measure which effectively eradicates the focus of infection. Symptoms and signs of right heart failure are usually delayed in patients who do not have coexisting pulmonary or left heart disease. REFERENCES Conway, N.: Endocarditis in Heroin Addicts, Br. Heart J. 31: 543, 1969. 2 Reyes, M. P., Palutke, W. A., Wylin, R. F., et al.: Pseudomonas Endocarditis in the Detroit Medical Center 1969-1972, Medicine (Baltimore) 52: 173, 1973. 3 Hodges, R. M., and DeAlvarey, R. B.: Puerperal Septicemia and Endocarditis Caused by Pseudomonas aeruginosa, J. A M. A 173: 1081, 1960.
4 Reyes, M. P., Arbulu, A, and Lerner, AM.: Treatment-Resistant Pseudomonas Endocarditis (Abstr.), 1. Clin. Invest. 50: 77a, 1971. 5 Arbulu, A., Thoms, N. W., and Wilson, R. F.: Valvulectomy Without Prosthetic Replacement, J. THORAC. CARDIOVASC. SURG. 64: 103, 1972. 6 Rivero-Carvallo, J. M.: Signo para el diagnostico de las insufficiensas tricuspideas, Arch. Inst. Cardio!. Mex. 20: 1, 1950. 7 Hansing, C. E., and Rowe, G. G.: Tricuspid Insufficiency: A Study of Hemodynamics and Pathogenesis, Circulation 45: 793, 1972. 8 Kay, J. H., Bustein, S., Feinstein, 0., et al.: Surgical Cure of Candida albicans Endocarditis With Open-Heart Surgery, N. Engl. 1. Med. 264: 907, 1961. 9 Stason, W. B., DeSanctis, R. W., Weinberg, A. N., et al.: Cardiac Surgery in Bacterial Endocarditis, Circulation 38: 514, 1968. 10 Shabetari, R., Adolph, R. 1., and Spencer, F. C.: Successful Replacement of the Tricuspid Valve 10 Years After Traumatic Incompetence, Am. 1. Cardio!. 18: 916, 1966. 11 Croxson, M. S., O'Brien, K. P., and Lowe, 1. B.: Traumatic Tricuspid Regurgitation: Long Term Survival, Br. Heart 1. 33: 750, 1971. 12 Cahill, N. S., Beller, B. M., Linhart, J. W., et a!.: Isolated Traumatic Tricuspid Regurgitation: Prolonged Survival Without Operative Intervention, Chest 61: 689, 1972. 13 Morgan, J. R., and Forker, A D.: Isolated Tricuspid Insufficiency, Circulation 43: 559, 1971. 14 Marvin, R., Schrank, J. P., and Nolan, S. P.: Traumatic Tricuspid Insufficiency, Am. J. Cardio!. 32: 723, 1973. 15 Halmagyi, D., Robicsek, F., Felhai, B., et a!.: Studies on Experimental Tricuspid Insufficiency in Dogs, Acta Med. Hung. 5: 347, 1954. 16 Spellman, M., and Balkisoon, B.: The Production and Evaluation of Ascites Secondary to Isolated Tricuspid Insufficiency in Dogs, Surgery 39: 37, 1956. 17 Michl, L., Shumacker, H. B., Jr., and Hobbs, D.: Tricuspid Valvulectomy, Surg. Gynecol. Obstet. 137: 590, 1973. 18 MUlier, 0., and Shillingford, J.: The Blood Flow in the Right Atrium and Superior Vena Cava in Tricuspid Incompetence, Br. Heart 1. 17: 163, 1955.
Erwin Robin, M.D., John Belamaric, M.D., Norman W. Thoms, M.D., Agustin Arbulu, M.D., and Sunilendu N. Ganguly, M.D., Detroit, Mich.
An increase in the frequency of tricuspid valve involvement by Pseudomonas aeruginosa has been reported among persons addicted to drugs.': ~ When this organism becomes resistant to antibiotics, the infection becomes medically intractable and the patient dies of the disease." 4 In order to avert this fatal outcome, five years ago we" introduced a new therapeutic approach consisting of complete removal of the tricuspid valve without prosthetic replacement. Case report A 19-year-old black man, addicted to heroin for 3 years, was admitted because of shortness of breath, chills, fever, and episodes of hemoptysis. There was no history of previous cardiopulmonary disease. The patient appeared to be chronically ill. The blood pressure was 120/85 mm. Hg; pulse From the Departments of Cardiology, Pathology, and Surgery, Hutzel Hospital, Wayne State University, Detroit, Mich. This study was supported by Michigan Heart Association Grant No. 306 705t and Hutzel Hospital Research and Education Fund. Received for publication May 13, 1974. Address for reprints: Erwin Robin, M.D., 100 William Dr., Elgin. 111. 60120.
rate 110 beats per minute and regular; respiratory rate 30 beats per minute, and oral temperature 101 F. The head, eyes, and nose were unremarkable. The jugular and carotid pulsations and the cardiac apical impulse were normal. There was no substernal heave. Heart sounds were of normal intensity. A Grade 2/6 systolic murmur was heard over the fourth and fifth left intercostal spaces close to the sternum; it increased to a Grade 4/6 with deep inspiration. Rhonchi were heard over both lung bases. The liver was palpable 2 em. below the right costal margin. It was neither tender nor pulsatile. The patient did not have ascites or leg edema. On admission, the white blood count was 14,000 per cubic millimeter with 85 per cent neutrophils. Six blood cultures grew Pseudomonas aeruginosa. A chest roentgenogram revealed a normal heart size, left pleural thickening, and bilateral patchy infiltrates. An electrocardiogram was normal. Initially the patient received 30 Gm. of carbenicillin intravenously and 300 mg. of gentamicin intramuscularly per day. After 6 weeks of treatment, he was still febrile and had persistent Pseudomonas septicemia. Carbenicillin was discontinued and intramuscular tobramycin was added in a daily dose of 300 mg. Gentamicin and tobramycin were continued for 3 weeks without improvement. Because of an unrelenting septic course, cardiac 0
461
462
The Journal of Thora cic a nd Card iovascular Surgery
Robin et al.
Fig. I. Dilated , hypertrophied right atrium (RA ) and right ventricle (RV ). The tricuspid leaflets a re absent and the annulus (ar ro w s) is free of bacterial vegetations.
catheterization was performed and a presumptive diagnosis of tricu spid va lvula r endocarditis with mild insufficiency was made . At operation, bacterial vegetations were found on all three leaflets of the tricuspid valve and on the endocardial surface of the right atrial a nd ventricular septa. Debridement of the septal vegetations and total remov al of the tricuspid valve without prosthetic replacement were performed. The right atrium and ventricle were irrigated with a solution containing 20 mg . of gentamicin and 5 Gm. of carbenicillin. Culture of the vegetations was positi ve for Pseudomonas aer u ginosa. After the operation, carbenicillin and tobrarnycin were administered for 4 weeks. The postoperative course was uneventful. Six months after the operation, the patient was readmitted for further evaluation. He was able to carry out his normal daily activities without difficulty. The only significant physical findings were a substern a l heave, distended neck veins, and a puls atile liver which extended 4 em . below the right costal ma rgin. There were no murmurs, ascites, or leg edema. A second cardiac catheterization was performed. One month later, the patient died from head injur ies sustained in an automobile accident. Autopsy. The most significant findings were confined to the heart and liver. There were extensive fibrous pericardial adhesions without compression or kinking of the major veins by the thickened pericardium. With the pericardium removed, the heart weighed 440 grams. The right atrium and the right ventricle were markedly hypertrophied and dilated ( Fig. I) . The diameter
of the right atrium me asured 6.0 em . Its muscular wall was thickened and measured as much as 0.4 em. The pectinate muscles were longer, wider, and thicker than normal and resembled the columnae carnae of the right ventricle. The right ventricular mu scle mass was increased, and the wall of the dilated right ventricle was 0.5 em. thick . The ring of the tricuspid valve was dilated and measured 15.0 em . The tricuspid valve leaflets were completely absent. and a fa int, grayish , linear thickening of the endocardium was present at their former insertion sites. Microscopic examination disclosed severe hypertrophy of myocardial fibers of the right atrium and ventricle (Fig. 2). A circumferential hyalinized scar was present at the tricuspid annulus. Examination of the liver revealed conge stive hepatomegaly ( 1,660 grams) , loss of centrolobular hepatocytes associated with fibrosis in some areas, and fibrosis of portal tracts with fibrous bridging between some of the tracts (Fig. 3). There was no evidence of viral hepatitis, talc crystals, or esophageal varices.
Discussion
Between 1969 and 1972 we have treated 21 heroin addicts with Pseudomonas endocarditis of the tricuspid valve. All were given carbenicillin, gentamicin, polymyxin B, and tobramycin in various dosages and combinations. Six patients were cured and 1 died . Fourteen in whom medical treatment failed were subjected to surgical ther-
Volume 68
Pseudomonas endocarditis
Number 3
463
September, 1974
Fig. 3. Liver with portal and central fibrosis. (Verhoeff-van Gieson; original magnification "125.) Inset: Central vein region. (Original magnification )(150.)
Fig. 2. Marked hypertrophy of myocardial fibers of the right atrium. Inset: Right atrial myocardium of a normal control specimen photographed at the same magnification. (Hematoxylin and eosin; original magnification "300.)
A.
I
r y r T Y
30 20
.
~
15
10
10
5f·-I,r-,j~V"vVVV'1/"11~Vv
5
:I:
E
~
SVC
RA
RV
SVC
RA
RV
Fig. 4. Pressure tracings obtained before (A) and after (B) total tricuspid valvulectomy. There is complete ventricularization of the right atrium (RA) and superior vena cava (SVC). RV, Right ventricle.
apy. In the first 2 patients, the tricuspid valve was removed and replaced by a prosthesis. Both died from persistent Pseudomonas septicemia. In the remaining 12, tricuspid valvulectomy without prosthetic replacement was performed. A bacteriologic cure was obtained in 10 of them, but 2 died from their unremitting infection. In the present case, bacterial involvement of the tricuspid valve was suspected because of fever, leukocytosis, Pseudomonas growth
in blood cultures, diffuse pulmonary infiltrates (septic emboli), and a systolic murmur which increased over the tricuspid area with deep inspiration." Analysis of the right atrial pressure curves obtained prior to the operation revealed normal V waves, which suggested that the degree of tricuspid insufficiency was mild (Fig. 4).' Cardiac surgery has been performed in the treatment of acute endocarditis when medical treatment had failed. B . " However,
The Journal of
464
Robin et al.
Thorocic and Cardiovascular Surgery
Table I. Cardiac hemodynamics before and after total removal of the tricuspid valve Before valvulectamy
After valvulectamy
Parameters
Base line
Exercise *
Base line
Exercise"
SVC (mm. Hg) RA (mm. Hg) IVC (mm. Hg) RV (mm. Hg) PA (mm. Hg) PWP (mm. Hg) Ao (mm. Hg) LV (mm. Hg) HR (beats/min. ) CH (L./min./sq. M.) SI (c.c./beat/sq. M.)
(4)
(4)
(12)
(11 )
(4 )
(4)
(12)
(11 )
(5)
(5)
(13 )
(12)
20/6
21/3
25/7
25/4
20/9 (16)
25/10 (17)
25/10 (15)
23/10 (15)
(6)
(7 )
(7 )
(6)
105/80 (90)
104/78 (92)
110/79 (93)
108/80 (90)
100/8
104/5
110/8
108/5
110
155
109
150
3.3
5.6
3.5
5.2
30
36
32
35
Legend: SVC, Superior vena cava. RA, Right atrium. IVC, Inferior vena cava. RV, Right ventricle. PA, Pulmonary artery. PWP, Pulmonary wedge pressure. Ao, Aorta. LV, Left ventricle. HR, Heart rate. CI, Cardiac index. Sl, Stroke index. "The patients exercised in the supine position on a bicycle ergometer at a work load of 150 Kg.-M. per minute for 3 minutes. tCardiac output was calculated from duplicate standard dye-dilution curves following injection of 5 mg. of indocyanine green into the pulmonary artery and sampling from the aortic root.
until our" initial report, nowhere in the English medical literature could we find any experience with tricuspid valvulectomy without prosthetic replacement in endocarditis. This procedure was selected because of (1) our initial failure to control the infection by removing the tricuspid valve and replacing it with a prosthesis; (2) the high rate of relapse of addiction among our patients, which could lead to infection of a prosthetic device; and (3) reports of long-term survival in patients with severe tricuspid insufficiency.l'"?" Our patient had been unsuccessfully treated for 9 weeks with carbenicillin, gentamicin, and tobramycin. His condition improved dramatically after the infected leaflets and septal vegetations were removed, with a bacteriologic cure achieved within the first postoperative week. At autopsy, there was no evidence of endocarditis (Fig. 1).
Most of the knowledge of the dynamic circulatory changes resulting from isolated tricuspid insufficiency has been derived from animal investigations. Halmagyi and associates-" demonstrated that the characteristic signs of tricuspid insufficiency develop only when at least 2 leaflets were functionally incompetent. Despite a significant increase in the right atrial pressure, as well as gross and microscopic evidence of hepatic congestion, neither heart failure nor ascites occurred. In contrast, Spellman and Balkiscon!" and more recently Michl and assoelates" were able to show that either partial or virtually complete defunctionalization of the tricuspid valve consistently results in ascites. MUller and Shillingford" have reported that in severe tricuspid incompetence the backflow equals or even exceeds the forward cardiac output. Notwithstanding these experimental observations, survival up
Volume 68 Number 3
Pseudomonas endocarditis
465
September, 1974
to 39 years has been reported in patients with isolated severe tricuspid insufficiency who do not have complicating pulmonary or left heart disease.r"> In our patient, the right atrium and ventricle behaved as a common hemodynamic chamber after removal of the tricuspid valve (Fig. 4). Except for the increase in pressure in the right atrium and venae cavae, the hemodynamic data observed 6 months postoperatively were similar to those obtained preoperatively (Table I). Thus, in spite of the overload produced by the regurgitant volume, the right heart was able to maintain a normal pulmonary pressure and flow. An important finding in the liver was the recent loss of hepatocytes, in addition to fibrosis. This suggests a slow, continuous loss of parenchymal tissue. Whether this process will lead to cirrhosis is debatable, especially in view of reports that patients have tolerated severe degrees of tricuspid insufficiency for several decades without evidence of hepatic dysfunction.t'"":' Clinical implications
In bacterial tricuspid valvulitis resistant to medical therapy, total excision of the tricuspid valve without prosthetic valve replacement is a life-saving measure which effectively eradicates the focus of infection. Symptoms and signs of right heart failure are usually delayed in patients who do not have coexisting pulmonary or left heart disease. REFERENCES Conway, N.: Endocarditis in Heroin Addicts, Br. Heart J. 31: 543, 1969. 2 Reyes, M. P., Palutke, W. A., Wylin, R. F., et al.: Pseudomonas Endocarditis in the Detroit Medical Center 1969-1972, Medicine (Baltimore) 52: 173, 1973. 3 Hodges, R. M., and DeAlvarey, R. B.: Puerperal Septicemia and Endocarditis Caused by Pseudomonas aeruginosa, J. A M. A 173: 1081, 1960.
4 Reyes, M. P., Arbulu, A, and Lerner, AM.: Treatment-Resistant Pseudomonas Endocarditis (Abstr.), 1. Clin. Invest. 50: 77a, 1971. 5 Arbulu, A., Thoms, N. W., and Wilson, R. F.: Valvulectomy Without Prosthetic Replacement, J. THORAC. CARDIOVASC. SURG. 64: 103, 1972. 6 Rivero-Carvallo, J. M.: Signo para el diagnostico de las insufficiensas tricuspideas, Arch. Inst. Cardio!. Mex. 20: 1, 1950. 7 Hansing, C. E., and Rowe, G. G.: Tricuspid Insufficiency: A Study of Hemodynamics and Pathogenesis, Circulation 45: 793, 1972. 8 Kay, J. H., Bustein, S., Feinstein, 0., et al.: Surgical Cure of Candida albicans Endocarditis With Open-Heart Surgery, N. Engl. 1. Med. 264: 907, 1961. 9 Stason, W. B., DeSanctis, R. W., Weinberg, A. N., et al.: Cardiac Surgery in Bacterial Endocarditis, Circulation 38: 514, 1968. 10 Shabetari, R., Adolph, R. 1., and Spencer, F. C.: Successful Replacement of the Tricuspid Valve 10 Years After Traumatic Incompetence, Am. 1. Cardio!. 18: 916, 1966. 11 Croxson, M. S., O'Brien, K. P., and Lowe, 1. B.: Traumatic Tricuspid Regurgitation: Long Term Survival, Br. Heart 1. 33: 750, 1971. 12 Cahill, N. S., Beller, B. M., Linhart, J. W., et a!.: Isolated Traumatic Tricuspid Regurgitation: Prolonged Survival Without Operative Intervention, Chest 61: 689, 1972. 13 Morgan, J. R., and Forker, A D.: Isolated Tricuspid Insufficiency, Circulation 43: 559, 1971. 14 Marvin, R., Schrank, J. P., and Nolan, S. P.: Traumatic Tricuspid Insufficiency, Am. J. Cardio!. 32: 723, 1973. 15 Halmagyi, D., Robicsek, F., Felhai, B., et a!.: Studies on Experimental Tricuspid Insufficiency in Dogs, Acta Med. Hung. 5: 347, 1954. 16 Spellman, M., and Balkisoon, B.: The Production and Evaluation of Ascites Secondary to Isolated Tricuspid Insufficiency in Dogs, Surgery 39: 37, 1956. 17 Michl, L., Shumacker, H. B., Jr., and Hobbs, D.: Tricuspid Valvulectomy, Surg. Gynecol. Obstet. 137: 590, 1973. 18 MUlier, 0., and Shillingford, J.: The Blood Flow in the Right Atrium and Superior Vena Cava in Tricuspid Incompetence, Br. Heart 1. 17: 163, 1955.