2020 Scientific Sessions

Title

TRANS-SEPTAL ANGIOVAC DEBULKING OF MITRAL VALVE ENDOCARDITIS

Introduction

There is a growing need for minimally invasive methods of treating infective endocarditis in patients who are at high risk for surgery. AngioVac is currently being used for the treatment of right sided endocarditis, however percutaneous treatment of left sided infective endocarditis has not been well described.

Clinical Case

Our patient is an 86 year old female who was treated for Streptococcus gordonii bacteremia with 4 weeks of antibiotics a month prior to her admission. She has history of TAVR in 2016, coronary artery disease, carotid disease and chronic kidney disease. She presented with abrupt onset slurred speech. MRI revealed multiple punctate infarcts in the left and right hemisphere concerning for embolic disease. She underwent TEE which revealed large echogenic, mobile density attached to the posterior mitral leaflet measuring 1.1 x 1.0 cm. There was trace mitral regurgitation. She was referred for surgical intervention but turned down due to comorbidities and advanced age. Blood cultures were negative; however given the risk of further embolic strokes the decision was made to proceed with trans-septal AngioVac debulking of the mitral valve vegetation with Sentinel Cerebral protection.

Procedure was performed with general anesthesia and TEE guidance. Sentinel filters were deployed in the left common carotid and innominate arteries through the right radial artery for peri-procedural cerebral protection against embolization. Right femoral vein was accessed and serially dilated, followed by placement of a 26Fr Gore dryseal sheath. Left femoral artery was accessed and serially dilated, followed by placement of a 16 Fr reinfusion cannula. A Baylis sheath was advanced into the RA and trans-septal puncture was performed under TEE guidance. An Amplatz super stiff guidewire was advanced into the left superior pulmonary vein. The septum was dilated with 14x40mm balloon. The AngioVac circuit was connected. The AngioVac Gen3 C180 cannula was advanced into the left atrium and the obturator was removed. Circuit was initiated and debulking of the vegetation was performed under TEE guidance with the C180 cannula in the fully flexed position. Patient remained hemodynamically stable during debulking utilizing the arterial-arterial reinfusion circuit. TEE demonstrated significant reduction in vegetation size. The AngioVac cannula was removed and blood from the circuit was returned to the patient by perfusion. TEE demonstrated left-to-right flow across the atrial septum; the patient remained hemodynamically stable and well oxygenated, therefore septal closure was deferred. Sentinel filters were removed. Hemostasis was achieved using Perclose sutures and radial hemoband. Postoperatively patient was monitored in the PACU and then transferred back to the telemetry floor. She did well and was discharged on post-operative day 4.

Discussion

The AngioVac system provides a minimally invasive option for debulking thrombus and vegetation. The system is commonly used for removal of intravascular material on the right sided structures, however the use in the left heart has not been well described. Our use of the AngioVac system to successfully debulk a mitral valve vegetation is unique. This procedure may provide an alternative management strategy for high risk/non-operative patients with left sided endocarditis.