Percutaneous transeptal mitral valve endocarditis debulking with AngioVac aspiration system

Abstract

Vacuum assisted aspiration with the AngioVac system has been well described for; right sided endocarditis, venous thrombus, lead related infection/thrombus aspiration and right sided cardiac mass evacuation. Percutaneous transeptal debulking with AngioVac for mitral valve endocarditis (MVE) in the inoperable or high surgical risk patient has not been well defined. A significant proportion of high/prohibitive surgical risk patients with left sided infective endocarditis (IE) are not offered valve surgery as patients in the acute active phase of IE have a high surgical mortality.Nonetheless, sequala of acute IE ie stroke, sepsis or hemodynamic instability in itself is associated with high morbidity and mortality without surgical treatment. A case report of an inoperable patient with methicillin sensitive staphylococcus aureus MVE who was offered MV vegetation debulking with the AngioVac Gen3 C 180 MV system is described. Preprocedural planning with attention to; optimal transeptal height puncture, use of sentinel cerebral protection device to decrease risk of procedure related cerebral embolism and venous extracorporeal membrane cannula, rather than arterial cannula for reinfusion, is described to avoid large bore arterial access related vascular complications. Further studies in a randomized manner are warranted to test these procedural techniques and determine outcomes of percutaneous aspiration of left sided IE with the AngioVac system in this highrisk inoperable cohort of patients.

Case report: Treatment of left-sided valve endocarditis using the Transapical AngioVac System and cerebral embolism protection device: A case series

“…Treatment of aortic or mitral prosthesis endocarditis with the AngioVac System, though a transapical or transeptal approach, has been previously described with encouraging results (4)(5)(6). In this study, we report the first cases of the native mitral valve and combined mitral and aortic prosthesis endocarditis treatment using the AngioVac System in combination with a cerebral embolic protection device.…”

“…Contrary to previous reports, we preferred an arterial reinfusion site ( 5 ), and we did not establish a parallel ECMO circuit ( 4 ) to support hemodynamics since the patient was not in septic shock and presented good cardiovascular conditions; however, we included an oxygenator that increased the filter efficacy of the system. For this reason, an ACT > 450 s was achieved with no significant periprocedural bleeding complications.…”

“…Using a totally ventricular approach without crossing the valve under accurate real-time TEE guidance to enable optimal alignment with the MV orifice might lower this risk. Alternatively, a transeptal approach has been described ( 5 , 6 ). However, after using the transeptal approach, the iatrogenic septal atrial defect might need to be closed with a closure device, but this occurrence is rare.…”

“…Another drawback of this procedure is the risk of stroke due to mass embolization. For this reason, we decided to position a cerebral embolism protection device as reported by other authors ( 5 , 6 ). This procedure is easy and safe and does not significantly prolong the fluoroscopy time of the procedure.…”

“…It consists of a suction cannula, an extra-corporeal circuit including a filter, and a reinfusion cannula. Recently, off-label use of this technology has been prescribed for leftsided masses removal (4)(5)(6) even with concerns about cerebral embolization. Cerebral embolization prevention systems (TriGuard, Keystone Heart Ltd., Herzliya, Israel; Sentinel, Boston Scientific) are occasionally used in heavy calcified native aortic valves during TAVI procedures.…”