[HSF] Traumatic tricuspid regurg

[Nasser F. Abou'Seada]

Dear Nand 
an interesting case. the ECHO did not pass through. 
Were I in your shoes, I'd take more blood cultures, start an empirical 4
drug regimen of Antibiotics, for 6-8 weeks, modified by culture results as
they appear. I'd opt to operate should the condition is stable, in 2-4 weeks
of therapy, or else sooner should the haemodynamics show deterioration.
Depending on operative findings, I would preserve the leaflets as much as
possible. Re-attaching the torn papillary muscle vs neo-chordae implantation
to the remaining papillary muscle would be my main choices. I'd certainly
put a ring, most probably will be required after that period of RV volume
overload. A bioprosthesis would be my last choice. I'd complete the
antibiotics course after the operation in all cases. 

Parameters of infection can be followed, not depending only on C/S tests
.... a combined CRP/ WBC-DLC/ Plat. count should provide an easy monitor
before antibiotics are started. Perhaps Claudia can cast more light on more
accurate parameters. 

Good luck with your interesting case. Please keep us posted. 

NFA

> From: nand kejriwal
> Dear members
>  An interesting case has been referred to me. The patient is a 65 year old
> lady who underwent dual chamber pacing a few years ago. Recently she
> presented to the cardiologist with pacemaker pocket site infection. The
> cultures did not grow any bug, but the generateor was eroding through the
> skin. Last week the cardiologist pulled out all the hardwares. Apparently
he
> tore one of the pap m of the TV while removing the RV lead. Now the
patient
> has severe TR. I am enclosing the echo frames showing the bit of pap m
with
> attached chordae flopping in & out of RV resulting in severe TR. The
patient
> had mild to mod TR before the lead removal. There is no evidence of TV
> endocarditis on echo. The annulus measures 40mm. Normal coronaries.
> 
> What is the best option?
> Repair by suturing the muscle back and putting an annuloplasty ring? Will
it
> work? My concern is that if the lead were infected, would it be wise to
> leave the leaflets behind?
> 
> Or, remove all the leaflets with chordae and insert a bioprosthesis?
> 
> I am also planning to attach RV & LV epicardial leads. I shall sew the LV
> lead close to the 1st OM artery posteriorly. What is the best spot for the
> RV lead?
> 
> Thanks
> 
> Nand