Tricuspid Valve Infective Endocarditis in People Who Inject Drugs: A Single-Center Comparison of Percutaneous Mechanical Aspiration Versus a Surgical Approach

Background: People who inject drugs (PWID) comprise the majority of patients with native tricuspid valve (TV) endocarditis. While some patients require surgical repair or replacement of their TV, many may be deemed ineligible for surgical management due to high operative risk or patient preference. Vacuum-assisted percutaneous mechanical aspiration (PMA) has emerged as a potential alternative to surgical management in this population. Methods: We retrospectively reviewed PWID hospitalized with endocarditis at a single tertiary care center (2016–2025) who underwent an isolated tricuspid valve (TV) procedure. Demographics, substance use, comorbidities, pathogens, and outcomes were analyzed. Results: Forty PWID with TV endocarditis who underwent an isolated TV procedure were identified. Mean age was 34 ± 7 years; 27 (67.5%) were female and 6 (15.0%) were Black or African American. Seventeen patients underwent percutaneous mechanical aspiration (PMA). Large vegetations (>2 cm) were more common in the PMA group (68.8% vs 59.1%). Procedural success was higher with surgery than PMA (95.7% vs 88.2%). Clinical success, a composite of procedural success, treatment completion, and lack of need for reintervention, was higher in the surgical group (73.9% vs 58.8%). PMA was associated with greater postoperative intensive care utilization (>48 hours; 35.3% vs 30.4%), longer hospital length of stay (median 18 vs 16 days), and higher need for reintervention within one year (11.8% vs 4.3%). Conclusion: PMA had a lower rate of procedural and clinical success compared with surgery. Outcomes may be reflective of baseline differences between groups. This finding needs to be closely followed in larger cohorts and case-control studies to determine if PMA is in fact a reasonable alternative to surgical management.