Role of AngioVac in the Management of Severe MRSA Tricuspid Endocarditis With Multisystem Complications

Right-sided infective endocarditis (IE) caused by methicillin-resistant Staphylococcus aureus (MRSA) in people who inject drugs often causes septic pulmonary emboli and critical illness, and many of these patients are too unstable for cardiac surgery when they present. We report a 38-year-old woman with active intravenous drug use, untreated hepatitis C, and a seizure disorder who presented with MRSA bacteremia, a large tricuspid valve vegetation, and cavitary septic pulmonary emboli complicated by respiratory failure, shock, and empyema. Despite 33 days of antibiotics, she remained febrile with progressive pulmonary complications, and cardiothoracic surgery judged her too high risk for valve replacement. She underwent percutaneous vegetation debulking with the AngioVac system through femoral venous access, with removal of approximately 80% of the vegetation and no procedural complications. Her subsequent course included massive hemoptysis with cardiac arrest, bronchial artery embolization, video-assisted thoracoscopic decortication, tracheostomy, and gastrostomy, after which she stabilized and was discharged to a long-term acute care hospital. Approximately 3 months later, she underwent tricuspid valve replacement and survived the operation. This case shows how percutaneous aspiration can serve as a bridge to definitive valve surgery in critically ill patients with right-sided IE who are not initial surgical candidates, and it highlights the multidisciplinary care these patients need.