Surgical Management of Tricuspid Valve Infective Endocarditis: A Systematic Review and Meta-Analysis

Background: This meta-analysis compares the early and late outcomes of valve repair versus replacement, the primary surgical strategies for tricuspid valve infective endocarditis (IE). Methods: We searched MEDLINE and EMBASE databases until 2016 for studies comparing tricuspid valve repair and replacement. Results: The main outcomes were mortality, recurrent IE, and need for reoperation. There were 12 unmatched retrospective observational studies with 1,165 patients (median follow-up 3.8 years, interquartile range: 2.1 to 5.0). The most common indications for surgery were septic pulmonary embolism, left-sided IE, right-side heart failure, and persistent bacteremia. Median repair proportion was 59% and replacement was 41% among studies. The primary repair strategies are vegetectomy, De Vega procedure, annuloplasty ring, bicuspidization, and leaflet patch augmentation. Of valve replacements, 83% were bioprosthetic and 17% mechanical prostheses. There were no differences in perioperative mortality between tricuspid valve repair versus replacement (relative risk [RR] 0.62, 95% confidence interval [CI]: 0.26 to 1.46, p = 0.3). Long-term all-cause mortality was not different (RR 0.61, 95% CI: 0.22 to 1.72, p = 0.4). Valve repair was associated with lower recurrent IE (RR 0.17, 95% CI: 0.05 to 0.57, p = 0.004) and need for reoperation (RR 0.26, 95% CI: 0.07 to 0.92, p = 0.04) but a trend toward greater risk of moderate to severe tricuspid regurgitation (RR 4.14, 95% CI: 0.80 to 21.34, p = 0.09). Furthermore, tricuspid valve repair is associated with lower need for permanent pacemaker (RR 0.20, 95% CI: 0.11 to 0.35, p < 0.001). Conclusions: Tricuspid valve repair and replacement offer similar long-term survival. Valve repair may offer greater freedom from recurrent IE and reoperation as well as freedom from pacemaker and should be the preferred approach for patients with tricuspid valve IE.