Title
Debulking of large mobile mass on bioprosthetic mitral valve using a Novel ŌNŌ™ Retrieval Device for Embolic Protection in a patient with mycotic stroke Introduction
Patients with prosthetic valve endocarditis and prohibitive surgical risk may benefit from transcatheter interventions, however periprocedural embolic complications are a major concern. Currently there is only one approved device for embolic protection during left sided transcatheter interventions that protects only brachiocephalic and left carotid artery. We present an off-label use of ŌNŌ
™ retrieval device (ŌNŌCOR Vascular) for comprehensive embolic protection in patient with recurrent mycotic embolism and prohibitive surgical risk.
Clinical Case
A 76-year-old male with a history of bioprosthetic mitral valve replacement due to
Corynebacterium endocarditis, abdominal aortic aneurysm with aorto-bilateral iliac stent graft repair, and chronic infection of the graft with recurrent abscess in the left groin due to
Corynebacterium, presented with fall and left humerus fracture. Blood cultures were positive for
Corynebacterium, and a TEE demonstrated a mobile mass on the posterolateral ventricular aspect of the bioprosthetic mitral valve. An aggressive antibiotic regimen was unsuccessful in the resolution of persistently positive blood cultures. Moreover, mycotic strokes were identified on MRI. Given that the patient was not a candidate for redo surgery, ID recommended debulking of the vegetation to improve the likelihood of sterilization with antibiotics. After an extensive multi-disciplinary discussion, we elected to perform aspiration of the vegetation with embolic protection via transaortic route under TEE guidance. Bivalirudin was used for anticoagulation. A Sentinel
® device was deployed via right radial artery followed by deployment of ŌNŌ basket in the ascending aorta (AAO) with amplatzer vascular plug II (AVPII) serving as a cap to trap any captured debris. Lightning Flash
™ (Penumbra, Inc.) device with HTORQ tip was used for computer-aided mechanical thrombectomy and we were unable to remove the portion of the mass that was adherent to the valve post. The Sentinel
®, AVP II and the ŌNŌ
™ device were removed and several pieces of debris identified within both the devices. The patient recovered from the procedure without any evidence of embolic events.
Discussion
Adequate embolic protection for left-sided cardiac interventions remains an unmet need. In this report, we detail the use of the ŌNŌ™ retrieval device positioned in the aorta as a protection device. To our knowledge this is the first description of its use as an embolic protection device. The ŌNŌ is a 12Fr compatible system consisting of a vascular sheath (7.5Fr lumen) capped with a flexible 35-mm wide nitinol basket which is flared and atraumatic and should completely oppose the descending aortic wall. The central lumen allows for introduction of various 7Fr compatible tools, including a vascular plug in our case which served as a distal cap to trap the captured debris. The embolic debris captured within the ŌNŌ basket, potentially would have caused significant harm. Until a device specifically designed to be positioned in the aorta to capture and remove embolic debris is available, the use of the ŌNŌ™ retrieval device provides a safe and effective approach to prevent devastating embolic events.