A second AngioVac procedure on day 31 successfully cleared bacteremia and stabilized a 48-year-old male with recurrent prosthetic tricuspid valve endocarditis who was not a surgical candidate.
Case Report (n=1)
Repeat AngioVac aspiration may serve as an effective palliative or debulking strategy for recurrent prosthetic tricuspid valve endocarditis in patients with prohibitive surgical risk.
Abstract Background Infective endocarditis (IE) is an infection of the endocardial surface of the heart, most commonly affecting cardiac valves. Right-sided IE, particularly of the tricuspid valve, is notably prevalent among individuals with a history of intravenous drug use (IVDU). The standard of care consists of prolonged antibiotics and surgical intervention, including valve replacement. However, patients with active IVDU often have prohibitive operative risk or are not considered surgical candidates due to anticipated reinfection. Aspiration systems such as the AngioVac device have emerged as a bridge to surgical intervention and a debulking method appropriate for high-risk populations. Case Presentation A 48-year-old male with a history of IVDU on Suboxone and IE post-tricuspid valve excision (2016) and bioprosthetic tricuspid valve replacement (2023), presented to the hospital with complaints of persistent fever and altered mental status. Blood cultures grew MRSA. Transthoracic echocardiogram revealed a large vegetation on the bioprosthetic tricuspid valve. On day 3, the patient underwent AngioVac removal of the vegetation. Postoperatively, he developed acute hypoxic respiratory failure requiring intubation and bronchoscopy, which revealed MRSA, Enterobacter cloacae, and Prevotella species. His course was further complicated by persistent MRSA bacteremia, candidemia, septic emboli (pulmonary & intracranial), and ceftaroline-induced neutropenia. Despite targeted antimicrobial therapy to blood culture findings (daptomycin, ceftaroline, metronidazole, micafungin), repeat imaging demonstrated persistent and evolving tricuspid vegetations. Considering the patient was not an appropriate candidate for surgical intervention, the patient underwent a second AngioVac procedure on day 31 of hospitalization following extensive multi-disciplinary team meetings. Cultures were negative post-procedure. He gradually improved, was successfully decannulated following earlier tracheostomy, completed a course of 8 weeks of IV Vancomycin and 6 weeks of Micafungin. Patient was discharged on Doxycycline and Rifampin for long-term antibiotic suppression. Discussion This case demonstrates unique aspects of patient care, including the repeated use of AngioVac in managing persistent prosthetic tricuspid valve IE, and addresses a potential gap in current IE management strategies. While AngioVac is increasingly reported as an alternative to open surgery in high-risk IE patients, the literature is limited in describing its repeated utilization and benefit. Given this patient’s history, this case may highlight the benefit of AngioVac when surgical options are limited and palliative/debulking measures are desired to medically optimize the patient and their prognosis. Repeat AngioVac procedures may reduce the risk of further septic embolization and enable enough stabilization for appropriate multi-disciplinary medicine interventions and potentially further surgical evaluation. This abstract is funded by: None
Mitchell et al. (Fri,) conducted a case report in Recurrent Tricuspid Valve Endocarditis (n=1). Repeat AngioVac procedure was evaluated. A second AngioVac procedure on day 31 successfully cleared bacteremia and stabilized a 48-year-old male with recurrent prosthetic tricuspid valve endocarditis who was not a surgical candidate.