Patient characteristics, procedural features and outcomes of percutaneous aspiration of large vegetations in patients with infective endocarditis

Introduction According to the European registry (ESC-EORP EURO-ENDO), embolic complications in bacterial endocarditis occur in a quarter of cases, while the length of vegetation >10 mm is an independent predictor of death. Although European guidelines recommend surgical treatment for large vegetations, 25-30% of patients are unable to undergo surgery due to contraindications. This cohort exhibits the highest mortality rate, reaching up to 44%. Percutaneous aspiration, a less invasive alternative, may reduce the risk of embolic complications and mortality. Purpose We describe the clinical features, indications, procedural details, in-hospital outcomes of patients undergoing percutaneous aspiration of large vegetations for endocarditis at a single German high-volume center. Methods This retrospective, single-arm single-center registry included all patients with percutaneous treatment of probable or definite endocarditis within last 5 years. Results 17 patients with totally 18 procedures were identified and included in the registry. In one case, the procedure was repeated due to the recurrence of vegetation. The mean age was 64±16 years, with 53% female patients. In the most cases (70.6%) vegetations were present on the tricuspid valve, including 3 patients who also had vegetations on intracardiac electrodes; in one case, vegetations were found exclusively on the electrodes. The mitral valve was involved in 3 cases (17.7%), and floating structures were aspirated via transseptal access in 3 cases and retrograde transaortic in one procedure. Upon admission 41.2% of patients had sepsis, including 2 patients with septic shock; septic pulmonary embolism was present in 29.4%, and embolism at other sites was observed in 23.5% of cases. All cases were discussed in heart team and surgery was declined due to prohibitive operative risk. All procedures were done under transesophageal or transthoracic echocardiography guidance. The mean size of the floating structures was 23±9 mm. Two mitral valve procedures were performed via transseptal approach and one aortic and mitral valve procedure was done via transbrachial arterial access. Steerable sheaths (8.5-12F) or large bore catheter (20-24F) and vacuum aspiration pump were used to aspirate the vegetations. Following the procedure, 1 patient developed septic pulmonary embolism, 2 patients had a recurrence of vegetations and 2 patients experienced worsening tricuspid regurgitation. No procedure-related systemic embolism especially no stroke cases and no access site complications were observed. The mean duration of antibiotic therapy was 40±23 days. Hospital mortality rate was 11.8%. Conclusion Percutaneous vegetation aspiration represents a potentially effective alternative to surgery, particularly in selected patients with inacceptable surgical risk. Further studies are required to refine patient selection criteria and establish precise indications for the procedure.