Gone in 60 Minutes!

Title : Percutaneous removal of Tricuspid Valve Vegetation in a patient of Right-sided Infective Endocarditis (RSIE), using AngioVac Device. Introduction: AngioVac is a vacuum-based device which was approved for percutaneous removal of unwanted intravascular materials (thrombi & emboli) in 2014. There are several reports of use of this device in aspiration of clots/thrombi from iliocaval, pulmonary & right atrium, but very limited data for its use in treatment of RSIE. I present the use of AngioVac device to extract a large vegetation from Tricuspid Valve in a RSIE patient which removed the source of septic embolization, & enhanced efficacy of antibiotics in rapid clearance of bacteremia. This novel technique may be used as a substitute for surgery where surgery is indicated but not possible due to high perioperative risk. Clinical Case : A 30 yr old female with h/o IV drug abuse & Hepatitis C presented with c/o fever, chest pain & sob for 2 wks. She was treated for Pneumonia but was transferred to us after she failed to respond to antibiotics & her symptoms worsened. On arrival, she was in severe sepsis & hypotension. CT chest showed presence of B/L cavitary lesions (s/o septic emboli). TTE/TEE showed presence of large tricuspid valve vegetation measuring 24x12 mm with moderate tricuspid regurgitation. Blood cultures were positive for MSSA bacteremia. IVDU was found to be the cause of bacteremia. Due to large size of the vegetation, persistent fever & bacteremia despite appropriate medical therapy, CT surgery was consulted for surgical removal of the vegetation, but patient was considered a poor surgical candidate. After discussion with family regarding patient's critically ill state, it was decided to extract the vegetation using AngioVac device, which was done successfully. Patient's condition improved & she was extubated next day after the procedure. Antibiotics were continued, she became afebrile, subsequent blood cultures were negative. 8 days after the procedure she was discharged to a rehab facility to finish 6 wks of intravenous antibiotics. Discussion : AngioVac device is composed of a venous drainage cannula & a reinfusion (venous return) cannula which are connected to an extracorporeal circuit & a commercially available pump head & bubble trap. Venous drainage cannula is a 22 Fr cannula with a funnel-shaped distal tip that can be advanced through 26 Fr sheath into venous system (RIJ) percutaneously. When bypass pump is started, a suction force is generated that facilitates aspiration of blood & thrombotic material into tip of the AngioVac cannula, circulating blood through a filter. After filtration, drained blood is returned to patient via a second percutaneously placed reinfusion- 20 Fr cannula through femoral vein. Epidemiological studies have shown 41% of bacteremic IVDU patients will have evidence of RSIE. High bacterial inoculums are associated with higher antibiotic resistance & reduced penetration, known as 'Inoculum effect'. Through vegetation debulking /extraction AngioVac reduces bacterial inoculum & enhances antibiotic activity, which hastens resolution of septic state & consequent hemodynamic compromise. Further research is needed to analyze potential benefits, outcomes or complications of this device in larger RSIE population.