Angiovac Debulking of a Watchman Flex device-associated thrombus
Presenter
Leonard Palatnic, D.O., University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
Leonard Palatnic, D.O., Christopher Manion, MD and David M. Zlotnick, M.D., FSCAI, University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY
Title
Angiovac Debulking of a Watchman Flex device-associated thrombus
Introduction
The incidence of prosthetic device endocarditis has increased with the emergence of percutaneous modalities utilized for the treatment of structural heart disease. The Angiovac mechanical aspiration system has been used to percutaneously debulk native valve, prosthetic valve and prosthetic device-associated thrombus and endocarditis. We present a unique case of Angiovac debulking of a Watchman Flex device-associated thrombus in the setting of refractory streptococcus intermedius endocarditis.
Clinical Case
A 72-year-old male with past medical history of coronary artery disease s/p coronary artery bypass graft surgery, atrial flutter/atrial fibrillation s/p left atrial appendage occlusion (LAAO) with a 31mm Watchman Flex device, severely reduced left ventricular systolic function s/p BiV ICD, and peripheral arterial disease who was admitted for septic shock secondary to Streptococcus Intermedium endocarditis. Trans-esophageal echocardiogram revealed a 1.0 x 1.8 cm echodensity on the left atrial surface of the Watchman device, and a 0.6 x 1.5 cm mobile echodensity attached to one of the pacing wires in the right atrium.
A multi-disciplinary heart team was contacted and the patient was deemed too high risk for cardiac surgery. The decision was made to proceed with AngioVac debulking and IV antibiotic therapy. Bilateral femoral venous access was obtained for the AngioVac system (16 Fr re-infusion catheter in the left common femoral vein and 26 Fr Gore Dryseal sheath in the right common femoral vein). Access was also obtained in the right radial artery for placement of a Sentinel cerebral protection device. After anticoagulation with heparin, a C180 AngioVac cannula was advanced into the right atrium and debulking of the lead vegetation was performed followed by device extraction (BiV-D) and placement of a temporary active fixation lead. TEE post-extraction demonstrated a residual mobile SVC thrombus/vegetation. The AngioVac C180 was advanced into the SVC and debulking was performed. Using the Bayliss versacross system and TEE guidance, a trans-septal puncture was performed. An Amplatz wire was advanced into the superior pulmonary vein. The septum was dilated with a 12x40mm balloon. An F18 85 AngioVac cannula was advanced into the left atrium and debulking of the Watchman device was performed, with significant reduction (~95%) achieved. Minimal residual thrombus was seen post-debulking. The AngioVac cannula was removed, and TEE demonstrated a mild residual ASD with left-to-right shunting and no significant hypoxemia. There were no new neurologic deficits post-procedure. His cultures subsequently cleared and he had BiV-D reimplanted ten days later. He was discharged home with a six-week course of IV antibiotics as per the Infectious Disease service.
Discussion
LAAO device-related thrombus has been described however device related infection remains a rarely reported complication despite increased device implantations. We report a unique case of AngioVac debulking of a Watchman Flex device-associated thrombus in the setting of refractory endocarditis. This treatment modality may be used as an alternative to cardiac surgery in the management of device related infection and thrombosis especially in patients with high or prohibitive operative risk.