Trivalvular/bivalvular heart: A philosophical, scientific and therapeutic concept

Background and aim of the study: In 1967, following the replacement of infe cted tricuspid valves in drug addicts with incurable endocarditis, all pati ents died. The study aim was to determine if tricuspid valve removal, rathe r than replacement, might offer these patients an improved outcome. Methods: Since July 1970, we have operated on 55 patients with intractable right-sided endocarditis. Before surgery, all had a history of intravenous drug abuse (IVDA) (duration range: 2-20 years; 5 years in 38 cases). In 53 patients the tricuspid valve was excised without replacement; the pulmonary valve was also removed in two cases. Results: Six (11%) patients died within six weeks of surgery, and 11 died b etween six months and 24.5 years. Ten of the late deaths were related to IV DA. Among 49 patients who survived surgery for six months to 29 years, 24 ( 50%) returned to the use of illicit drugs. Only six patients eventually req uired insertion of a heart valve prosthesis; of these, four died, two due t o repeat IVDA. Of 38 long-term survivors (range: 9-29 years), two have a no n-functioning bioprosthesis in the tricuspid position, 35 have a trivalvula r heart, and one has a bivalvular heart. Only three patients required diure tics and digitalis. Conclusion: IVDA patients with intractable right-sided infective endocardit is have the best chance of cure and long-term survival by undergoing tricus pid or tricuspid and pulmonary valve excision(s), without prosthetic replac ement. No published evidence or long-term follow up data indicate better su rgical treatment for this patient group. In this day and age of cost contai nment, these operations are economical. Operations that work well in non-ad dicted patients become costly and invariably are associated with a second e ndocarditis and death in inveterate IVDA cases.