Tricuspid valve vegetation debulking using the AngioVac system

Endovascular aspiration of native tricuspid valve vegetation using INARI catheter in a patient with methicillin-sensitive Staphylococcus aureus endocarditis

A middle-aged man presented to the hospital with chief complaint of worsening chest pain and shortness of breath. He was found to have methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, acute hypoxic respiratory failure secondary to MSSA pneumonia and septic emboli. The patient underwent a transesophageal echocardiogram which revealed a large, mobile tricuspid valve vegetation secondary to endocarditis. The patient was initially managed conservatively with intravenous antibiotics and supportive measures. However, his respiratory status worsened due to persistence of a large tricuspid valve vegetation which progressed to bilateral septic pulmonary emboli with peripheral cavitary lesions identified on follow-up CT of the chest. In order to debulk the large tricuspid vegetation, the patient successfully underwent endovascular mechanical aspiration of tricuspid valve vegetation utilizing the 20-Fr INARI curved Flowtriever (INARI Medical, CA) catheter. This case highlights a new, minimally invasive technique and device employed in treating native valve vegetations caused by endocarditis as an alternative approach to surgery.

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis

BACKGROUND

Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown.

OBJECTIVES

To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE.

METHODS

Two independent reviewers screened abstracts and full text for inclusion and independently extracted data.

DATA SOURCES

MEDLINE, Embase, and Web of Science.

STUDY ELIGIBILITY CRITERIA

Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included.

ASSESSMENT OF RISK OF BIAS

As this was a scoping review, risk of bias assessment was not performed.

METHODS OF DATA SYNTHESIS

Descriptive data was reported.

RESULTS

We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294).

CONCLUSIONS

While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BACKGROUND

Transcatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes.

METHODS

PubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed.

RESULTS

Data from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50-85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each.

CONCLUSIONS

Transcatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Outcomes and survival of patients undergoing percutaneous vegetectomy for right heart endocarditis

Backgrounds

AngioVac is used for the percutaneous removal of vegetations and for debulking of large vegetations in patients who are not surgical candidates.This study aims to identify the demographics, echocardiographic features, indications, improvement of the tricuspid valve regurgitation, and survival outcomes of patients who have undergone AngioVac vegetectomy reported in the literature.

Methods

A systematic review was performed to identify articles reporting suction thromectomy or vegetation removal using the AngioVac system for RSIE (right sided infective endocarditis). Survival on discharge was our primary outcome. Additionally, we evaluated indications for suction thrombectomy and TR improvement. Categorical variables were expressed as percentages and ratios.

Results

A total of 49 studies were identified. The most common risk factor was intravenous drug abuse seen in 45% (20/49) and cardiovascular implantable electronic device (CIED) in 45% (20/49). Circulatory shock was seen in 35% of patients. The causative organism was gram positive cocci (86%). Moderate to severe TR was present in 74% of cases with documented echocardiograms. Indications for AngioVac were poor surgical candidacy (81%) or to reduce septic emboli risk (19%). Survival at discharge was 93%. TR improvement was reported only in 16% cases and remained unchanged/worsened in 84%.

Conclusion

AngioVac procedure is an alternative treatment for critically ill patients who cannot undergo surgery. To understand the survival, safety and candidacy of patients undergoing this procedure, further randomized control studies and literature reviews are needed. The improvement or worsening of tricuspid regurgitation in patients with TR valve involvement is another factor to be investigated.

The Use of AngioVac in a Patient With Severe Infective Endocarditis Where Open Heart Surgery Is Contraindicated: A Case Report

Infectious endocarditis of the tricuspid valve (TV) is a common complication of intravenous (IV) drug use. Endocarditis caused by viridans streptococci can lead to heart valve vegetations, which may be life-threatening due to the potential for embolism and obstruction. The management of large valvular vegetations is often difficult due to the risks involved with open heart surgery, especially in patients with comorbid conditions. The AngioVac device (AngioDynamics Inc., Latham, NY) has been shown in rare cases to be effective at debulking vegetations without the need for invasive surgery. We present a 45-year-old male with a history of intravenous heroin use disorder, hepatitis C, spinal abscesses, and chronic anemia who experienced worsening shortness of breath, generalized weakness, bilateral lower extremity edema, dysuria with dark urine, and blood on toilet paper. Workup revealed a 4.39 × 4.35 cm tricuspid valve vegetation, severe tricuspid regurgitation (TR), acute renal failure, acute on chronic anemia, and thrombocytopenia from sepsis-induced disseminated intravascular coagulation (DIC). AngioVac was used to aspirate the vegetation and effectively reduced the size to 3.75 × 2.31 cm. Follow-up blood cultures revealed no growth after five days. This is the largest documented tricuspid valve vegetation with a successful implementation of the AngioVac to date. This therapy, in conjunction with intravenous antibiotics and hemodialysis, successfully sterilized the vegetation, prevented worsening presentation, and averted life-threatening complications, although severe tricuspid regurgitation persisted. Based on the findings of this case, the AngioVac device is a safe and effective treatment option for tricuspid valve endocarditis patients with large vegetation and severe comorbidities, which contraindicate open heart surgery.

AngioVac for Vegetation Debulking in Right-sided Infective Endocarditis: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate the utility of AngioVac-assisted vegetation debulking (AVD) in right sided infective endocarditis (RSIE) BACKGROUND: : AngioVac is a vacuum-based device that was approved in 2014 for the percutaneous removal of undesirable materials from the intravascular system. Although there are multiple reports on the use of the AngioVac device to aspirate right-sided heart chamber thrombi, data on its use to treat RSIE is limited.

METHODS

We performed a comprehensive literature search for studies that evaluated the utility of AVD. The primary outcomes of our study were the procedural success, defined as the ability of AngioVac to produce residual vegetation size <50% (RVS<50%) without serious procedural complications, and the clinical success, defined as composite of RVS<50%, in-hospital survival, absence of recurrent bacteremia, and valve function not requiring further intervention. The secondary outcomes included the individual components of the primary outcomes and average length of hospital stay. The pooled means and proportions of our data were analyzed using random effects model, generic inverse variance method, and represented with 95% confidence intervals (CIs).

RESULTS

A total of 44 studies, including 301 patients (mean age: 44.6±18.2 years, 71.6% males) were included. Procedural success was achieved in 89.2% of patients (95% CI:82.3%-93.6%, I²=0%). Clinical success was achieved in 79.1% of patients (95%CI:67.9%-87.2%, I²=15%). Overall survival rate was 89.7% (95% CI:83.1%-93.9%%, I²=9%).

CONCLUSIONS

Our meta-analysis demonstrates that AVD is a promising therapeutic option for RSIE offering a high success rate with an acceptable complication rate across a wide range of patients.

Percutaneous Large Thrombus and Vegetation Evacuation in the Catheterization Laboratory

Intracardiac and intravascular thrombi are associated with significant morbidity and mortality. Although surgery remains the gold standard treatment option, these patients often have multiple comorbidities that can make surgical options challenging. With advancements in catheter-based technologies, there are now percutaneous treatment options for these patients. The AngioVac is a percutaneous vacuum-assisted thrombectomy device FDA-approved for removal of intravascular debris that uses a venovenous extracorporeal membranous oxygenation circuit with a filter. Use of this device has now been reported in the removal of right atrial or iliocaval thrombi, debulking tricuspid vegetations, removal of vegetations from implantable cardiac devices, and pulmonary embolism.