Advanced Management of Tricuspid Endocarditis: A case study in a multidisciplinary care

Managing severe tricuspid endocarditis in a 33-year-old with IV drug use. Review the surgical approach, including AngioVac thrombectomy and dual bioprosthetic valve (tricuspid/aortic) replacement, emphasizing multidisciplinary care and successful one-year follow-up.

Author: Norton Healthcare

Published: December 18, 2025

The patient

A 33-year-old male with heroin use and an abscess to left arm: Workup revealed methicillin-sensitive Staphylococcus aureus bacteremia with tricuspid endocarditis and pulmonary septic emboli with cavitations and central nervous system septic emboli. This condition is common with intravenous drug use and increasing in prevalence.

His course was complicated by COVID-19.

The challenge

A transesophageal echocardiogram (TEE) showed the patient with moderate tricuspid regurgitation (TR) with highly mobile vegetation 2.2 centimeters by 0.8 centimeters.

AngioVac thrombectomy debulked the infection by more than 60%. The patient completed six weeks of antibiotics and followed up with cardiac surgery with repeat TEE. This repeat TEE demonstrated 2.6 centimeters vegetation on the tricuspid valve with now severe TR and aortic vegetation 1.8 centimeters by 1.3 centimeters with severe aortic insufficiency and paravalvular abscess and enlarged right ventricle with reduced function.

The solution

Open heart surgery was performed with aortic and tricuspid valve replacement with repair of aortic root abscess. Mechanical valves weren’t offered because of the high risk of noncompliance with coumadin and lab monitoring.

Patient completed intravenous antibiotics and was discharged.

Ongoing treatment included multidisciplinary collaboration among cardiology, cardiac surgery and infectious diseases specialists, as well as hospitalists. Treatment spanned months and required support from harm reduction, care management and social work teams for safe discharge plans.

The result

The patient followed up one year later with cardiology and showed continued sobriety. He used methadone for medication-assisted treatment and saw harm reduction regularly. Four months after surgery, his ejection fraction was normal. The new valves were functioning normally.

Intervention saved heart function, reversed the stress on the right ventricle — which was showing early compromise — and prevented full annular antrioventricular rupture, which would have caused death.