Substance Use Disorder Associated Tricuspid Endocarditis: Staged Surgery from Valvectomy to Replacement

Structured Abstract Objectives Optimal surgical treatment of infective tricuspid infective endocarditis (TVIE) is controversial in the setting of active substance use. This study evaluated patients that had endocarditis that was not amenable to tricuspid valve repair. In these patients, a valvectomy was performed to remove the diseased tissue. Patients were then offered a subsequent tricuspid valve replacement following proper follow-up and drug abstinence. Methods A single-center database was queried (2015-2025) to identify adults that underwent valvectomy for TVIE not amenable to repair after failed medical therapy and persistent positive blood cultures. Valvectomy patients with documented IV drug abstinence for 6 months were considered for staged tricuspid valve replacement (sTVR). Patients with persistent drug use did not receive further surgical treatment. Baseline characteristics, outcomes, and survival were evaluated. Results 153 patients underwent surgical treatment for TVIE. Tricuspid valvectomy was required in 51 patients. 66% of the patients were females, with a median age of 30 years. There were 2 operative mortalities (3.9%). 1, 5, and 8-year survival was 91%, 62%, and 51%, respectively. 26 (51%) received a sTVR and 25 (49%) did not receive sTVR (Non-sTVR). In those that received an sTVR, there were 0 operative mortalities, median postoperative length of stay was 6 days, and median hours in the ICU was 30 hours. IVDU relapse following sTVR was present in 57.7% of patients. Survival at 1 and 5-years following the sTVR was 100% and 60%. Conclusion Tricuspid valvectomy is an acceptable initial treatment in high-risk patients. Tricuspid valve replacement after completing an abstinence program from IV drugs for 6 months has acceptable outcomes in a complex patient population. Further study of long-term outcomes is warranted.