Abstract
Background
Patients in cardiogenic shock secondary to endocarditis and multivalvular heart disease have a high surgical risk. Transcatheter valve aspiration followed by transcatheter valve intervention might be a strategy to salvage carefully selected patients.
Case Summary
A 63-year-old woman with subaortic membrane and severe aortic stenosis/regurgitation was scheduled for membrane resection, aortic root enlargement, and aortic valve replacement. Two weeks before operation, she developed mitral valve endocarditis. Because of cardiogenic shock, she was placed on venoarterial extracorporeal membrane oxygenation with a left atrial vent. Transcatheter aspiration of mitral vegetation resulted in minimal residual valve pathology with culture clearance; the patient received transcatheter aortic valve replacement and was discharged to a rehabilitation facility.
Discussion
Surgery in patients with multivalvular disease with endocarditis and cardiogenic shock can be very high risk. Transcatheter aspiration of endocarditis and treatment of valvular disease might be an alternative to high-risk surgical therapy.
Take-Home Messages
Surgical treatment has been the only available option for patients with endocarditis and multivalvular disease. In these patients at very high operative risk and with appropriate valvular anatomy, transcatheter aspiration of endocarditis followed by transcatheter therapy of multiple valvular lesions can be feasible alternative.
Key words: cardiogenic shock, endocarditis, percutaneous mechanical aspiration, severe aortic insufficiency, subaortic membrane, transcatheter aortic valve replacement
Graphical Abstract
Infective endocarditis remains a significant global problem with 10 to 20 cases per 100,000 per year with substantial mortality.1 The standard treatment has been antibiotics, with surgical therapy for valvular dysfunction, persistent infection, recurrent emboli, or large vegetations.2 Although early surgery improves outcomes in select patients,3 mortality for patients with cardiogenic shock can exceed 20%.4 Recently, percutaneous aspiration has emerged as an alternative to surgery in patients with high operative risk.5 Additionally, transcatheter mitral valve edge-to-edge repair and transcatheter aortic valve replacement (TAVR) for endocarditis have been described.6, 7, 8 However, it is challenging to manage patients with active endocarditis and multivalvular disease who require transcatheter therapy.
Take-Home Messages
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Surgical treatment has been the only available option for patients with endocarditis and multivalvular disease.
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In these patients at very high operative risk and with appropriate valvular anatomy, transcatheter aspiration of the endocarditis followed by transcatheter therapy of multiple valvular lesions can be a feasible alternative.
History of Presentation
We present a 63-year-old woman with cardiogenic shock secondary to mitral valve endocarditis and severe aortic valve stenosis/regurgitation with subaortic membrane. One month before presentation, our team evaluated her with comprehensive imaging (Figures 1 and 2, Video 1). Given low operative risk, we scheduled her for subaortic membrane resection and surgical aortic valve replacement. Two weeks before the operation, she presented with fevers. Blood cultures grew out Staphylococcus lugdunensis, and transthoracic echocardiography showed mitral valve vegetation with moderate mitral regurgitation (MR) and stenosis (Figure 3, Video 2). Within 24 hours of transfer to our hospital, she developed cardiogenic shock secondary to severe mixed aortic disease and sepsis.
Figure 1.
Echocardiography of Severe Aortic Stenosis/Insufficiency
(A) Parasternal long view of aortic valve. (B) Parasternal long view of aortic insufficiency jet. (C) Apical 5-chamber view of aortic valve. (D) Apical 5-chamber view of aortic insufficiency jet. (E) Continuous wave Doppler of aortic valve showing peak velocity of 4.5 cm/s with mean gradient of 51 mm Hg. (F) Continuous wave Doppler of aortic valve showing severe aortic insufficiency.
Figure 2.
Computed Tomography of Aortic Valve, Aortic Annulus, and Subaortic Membrane
Gated computed tomography showing AV in diastole and systole, and areas of the annulus, LVOT, and subaortic membrane (arrow). AV = aortic valve; LVOT = left ventricular outflow tract.
Figure 3.
Transthoracic Echocardiography of Mitral Valve Vegetation
(A) Apical 2-chamber view of mitral vegetation. (B) Apical 3-chamber view of mitral vegetation.
Past Medical History
She has a history of native aortic valve endocarditis in 2015 managed medically, and right breast cancer status post right mastectomy/chemotherapy in 2003.
Investigations
Transesophageal echocardiography (TEE) revealed a large mitral valve vegetation (1.6 × 1.2 cm) causing moderate MR/stenosis (mean gradient: approximately 8 mm Hg) (Figure 4, Video 3). TEE also confirmed a subaortic membrane and severe aortic stenosis/insufficiency with peak aortic velocity of 5.8 m/s and mean gradient of 74 mm Hg (Figure 5, Video 4).
Figure 4.
TEE of Mitral Valve Vegetation
(A) TEE of mitral valve vegetation. (B) TEE with color Doppler of mitral valve vegetation. TEE = transesophageal echocardiography.
Figure 5.
Transesophageal Echocardiography of Aortic Valve
(A) Mid-esophageal left ventricular outflow tract view (LVOT) and short axis of aortic valve. (B) LVOT and short-axis views aortic valve showing aortic insufficiency. (C) Continuous wave Doppler showing peak and mean aortic gradients.
Management
Given her cardiogenic shock and multivalvular dysfunction, our heart team deemed her high to extreme surgical risk. The patient was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO), after which a transcatheter left ventricular vent was placed to avoid left ventricular distension given severe aortic insufficiency. VA-ECMO was chosen over an Impella device (Johnson & Johnson) given prolonged support time and risk of hemolysis.
VA-ECMO and left ventricular vent
The left femoral vein, artery, and superficial femoral artery were accessed percutaneously using ultrasound. Via left femoral vein, a 21-F Tandem cannula (LivaNova) was advanced to the right atrium. Similarly, a 15-F Tandem cannula was placed in the left femoral artery. A 6-F Pinnacle Destination sheath (Terumo Interventional Systems) was placed in the left superficial femoral artery to connect to the side of the arterial cannula, providing antegrade flow to the left leg, and VA-ECMO was initiated.
For the left atrial (LA) vent, the right femoral vein was accessed and 2 8-F sheaths placed. One sheath accommodated the intracardiac echocardiography probe and via the other a VersaCross system (Boston Scientific Corp) was used for transseptal puncture. Over the VersaCross wire, a 21-F Tandem cannula was advanced into the left upper pulmonary vein (Figure 6) and connected to the left venous cannula.
Figure 6.
Fluoroscopic Views of Transseptal Puncture and LA Cannula Placement
(A) ICE-guided transseptal puncture with VersaCross system. (B) Left upper pulmonary vein angiogram. (C) LA cannula placement. ICE = intra cardiac echocardiography; LA = left atrial; RA = right atrial.
MV endocarditis aspiration
The next day we brought the patient to the catheterization laboratory to aspirate the mitral vegetation using the AngioVac system (AngioDynamics). This system comprises a 22-F or 25-F outer cannula with an inner cannula (18-F or 22-F) with a funnel that can be telescoped and steered.9 The inner cannula provides aspiration via an VA-ECMO circuit with blood returning via a cannula. For the return cannula, we placed a 17-F Tandem cannula in the right internal jugular vein. To insert the inner/outer cannula, a Safari wire (Boston Scientific Corp) was advanced via the LA cannula, and the cannula was changed to a 26-F Gore DrySeal sheath (Gore Medical). Via this sheath, we advanced the outer cannula into the left atrium, and then telescoped/flexed the inner cannula toward the mitral vegetation (Figure 7). After approximately 3 passes at approximately 3.0-L/min flow, the vegetation had been debulked (Figure 8, Videos 5 and 6). The AngioVac catheter was changed back to the 21-F Tandem cannula. Because of left radial arterial line dampening, we performed left subclavian angiography, revealing an axillary occlusion, and surgical embolectomy was performed. After the aspiration, multiple blood cultures showed no growth and echocardiography showed moderate MR or less.
Figure 7.
Fluoroscopic and Echocardiographic Views of the AngioVac System
(A) Fluoroscopic view of AngioVac system aiming toward mitral vegetation. (B) Echocardiographic views of AngioVac system aiming toward mitral vegetation.
Figure 8.
Transesophageal Echocardiography of Aspiration, and Images of Vegetation
(A) Transesophageal view of mitral vegetation. (B) Transesophageal view of AngioVac funnel aspirating vegetation. (C) Transesophageal view of mitral valve after vegetation aspiration. (D) Mitral vegetation in aspiration cannister. (E) Image of vegetation ex vivo. (F) Subclavian angiogram showing embolism to axillary artery. (G) Subclavian angiogram after embolectomy. (H) Embolic tissue retrieved from axillary artery.
TAVR procedure
The patient's subaortic membrane and small annular anatomy (area: 180 mm2) created uncertainty about feasibility of TAVR. Therefore, we performed computer modeling using DASI Simulations,10 which demonstrated that TAVR with a 20-mm SAPIEN 3 Ultra Resilia (Edwards LifeSciences) at nominal inflation could treat both the subaortic membrane and aortic valve without significant risk of rupture.
Six days after the aspiration, the patient underwent a TAVR in the catheterization laboratory. We placed a 6-F sheath in the right femoral vein for temporary pacing and a 14-F E-sheath via the right femoral artery. We performed TAVR using general anesthesia (Figure 9, Video 7), and TEE showed treatment of both the subaortic membrane and aortic valve with minimal perivalvular leak and no significant gradient (Video 8).
Figure 9.
Fluoroscopy of TAVR Deployment
(A) Baseline aortography. (B) TAVR positioning. (C) TAVR deployment. (D) Final aortography. TAVR = transcatheter aortic valve replacement.
Outcome and Follow-Up
The patient had no neurologic complications and was extubated the next day. VA-ECMO was weaned over 5 days, and she was decannulated at bedside; the 15-F left femoral artery was closed with a MANTA device (Teleflex International), and the other sheaths were removed with manual pressure. Postprocedural echocardiography showed ejection fraction >70%, approximately 20 mm Hg mean gradient and no perivalvular leak, and moderate MR or less (Video 8). She was discharged to a rehabilitation facility 11 days later.
Discussion
Surgical therapy has been the only available option for complicated endocarditis and multivalvular disease. Not only does surgery effectively remove infected tissue, but it also permits the repair/replacement of valvular abnormalities. However, the risk of operative mortality and morbidity remains very high, particularly for those with multiorgan failure, cardiogenic shock, and prior valve replacement. Therefore, increasing efforts are being made to explore the role of transcatheter therapies and change the historic treatment paradigms.
The first challenge is to extract enough infected tissue so that the septic physiology and bloodstream infection resolve. Furthermore, it is hoped that debulking the endocarditic burden prevents the insidious destruction of valvular function that often occurs. In our patient, we were able to debulk the mitral valve vegetation sufficiently to clear blood cultures within 48 hours and to stabilize valve function. In our patient, postaspiration echocardiography over 2 weeks showed significantly less MR than baseline.
Nonetheless, this procedure comes with notable risks. Foremost, distal embolism is a serious possibility. It is possible that the AngioVac system reduces embolism because of continuous, high flow rates via the VA-ECMO circuit and the ability to aspirate before actual vegetation contact. For more safety, cerebral protection should be considered in these cases. In our patient, radial artery spasm/occlusion prevented us from deploying a Sentinel Cerebral Protection System (Boston Scientific Corp); notably, embolism did occur, requiring surgical embolectomy of the left axillary artery. Finally, even after successfully debulking the lesion, valve preservation is uncertain. It is possible that our patient's MR could have worsened, either secondary to aspiration or to persistent infectious destruction of the valve.
With new or persistent valvular dysfunction, the surgical dilemma persists. If surgery remains high risk, further transcatheter therapy could be considered if anatomically feasible. For example, if aspiration in our patient had revealed a posterior prolapse with severe MR, transcatheter edge-to-edge repair might have been feasible. Conversely, edge-to-edge repair might not be possible in the presence of perforations. It is conceivable that once transcatheter mitral valve replacement is commercially available, transcatheter mitral valve replacement for such patients could be possible. It is unclear, however, who would require lifelong antibiotic suppression. Furthermore, staging patients after transcatheter valvular therapy in those with cardiogenic shock for surgery is also feasible and well established in our practice.
In our patient, with acceptable residual MR after aspiration, we thought that transcatheter therapy of the aortic valve disease was warranted. Because numerous blood cultures were negative without new aortic valve lesions and the patient still on VA-ECMO, we proceeded with TAVR. Her subaortic membrane and constrained annular anatomy did pose uncertainties, but our use of computer modeling with DASI Simulations provided reassurance that TAVR would risk annular rupture despite significant oversizing. Furthermore, it was necessary to treat the AI to be able to wean the patient off VA-ECMO.
Even though TAVR could risk trapping infected aortic material and/or leaving a residual gradient, transcatheter therapy allows correction of critical aortic valve physiology. With transcatheter therapy, we can rescue the patient from cardiogenic shock so that if the patient must proceed with surgical therapy later, the risk of surgery has been greatly attenuated. Conversely, if hemodynamic results are acceptable, surgery can be avoided and the patients followed clinically.
Conclusions
We present a case of transcatheter mitral valve endocarditis aspiration and TAVR in a patient with cardiogenic shock secondary to multivalvular disease. In patients with acute cardiogenic shock and high risk for traditional surgery, transcatheter valve therapies can provide resolution of multivalvular disease.
Funding Support and Author Disclosures
Dr Thourani has received grant/research support from Abbott Vascular, Boston Scientific, Atricure, Croívalve, Edwards Lifesciences, Highlife, Jenavalve, LaPlace, Medtronic, Pi-Cardia, Tricares, and Trisol; and has equity in Dasi Simulations, Trisol, and Pi-Cardia. Dr Yadav is a speaker and consultant for Edwards Lifesciences, Abbott, and Medtronic; is on the advisory board for Dasi Simulations, PiCardia, and Trisol; and has investments in Dasi Simulations and Excision Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Transthoracic Echocardiography of Aortic Valve
Parasternal long and apical 5-chamber views showing severe aortic stenosis/insufficiency with corresponding continuous wave Doppler.
Transthoracic Echocardiography of Mitral Vegetation
Apical 4-chamber views of mitral vegetation with and without color Doppler.
Transesophageal Echocardiography of Mitral Vegetation
Mid-esophageal views of mitral vegetation with and without color Dopper.
Transesophageal Echocardiography of Aortic Valve
Mid-esophageal view of subaortic membrane and aortic valve.
Transesophageal Echocardiography of Aspiration Procedure
AngioVac funnel is steered toward vegetation, engaging and aspirating it.
Echocardiography of MR
(A) Preoperative transthoracic echocardiography of MR. (B) Intraoperative transesophageal echocardiography of MR before aspiration. (C) Postoperative transthoracic echocardiography of MR. (D) Intraoperative transesophageal echocardiography of MR after aspiration. MR = mitral regurgitation.
Fluoroscopy of TAVR Deployment
Baseline aortography, TAVR positioning, TAVR deployment, and final aortography. TAVR = transcatheter aortic valve replacement.
Transesophageal Echocardiography of TAVR Deployment
Baseline (upper left), deployment (upper right), postdeployment (lower left), and continuous wave Doppler.
References
- 1.Dayer M.J., Quintero-Martinez J.A., Thornhill M.H., Chambers J.B., Pettersson G.B., Baddour L.M. Recent insights into native valve infective endocarditis: JACC Focus Seminar 4/4. J Am Coll Cardiol. 2024;83(15):1431–1443. doi: 10.1016/j.jacc.2023.12.043. [DOI] [PubMed] [Google Scholar]
- 2.Writing Committee M., Otto C.M., Nishimura R.A., et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. J Am Coll Cardiol. 2021;77(4):e25–e197. doi: 10.1016/j.jacc.2020.11.018. [DOI] [PubMed] [Google Scholar]
- 3.Kang D.H., Kim Y.J., Kim S.H., et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466–2473. doi: 10.1056/NEJMoa1112843. [DOI] [PubMed] [Google Scholar]
- 4.Gaca J.G., Sheng S., Daneshmand M.A., et al. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011;141(1):98–106. doi: 10.1016/j.jtcvs.2010.09.016. [DOI] [PubMed] [Google Scholar]
- 5.Haddad S.F., Lahr B.D., El Sabbagh A., et al. Percutaneous mechanical aspiration in patients with right-sided infective endocarditis: an analysis of the national inpatient sample database-2016-2020. Catheter Cardiovasc Interv. 2024;103(3):464–471. doi: 10.1002/ccd.30958. [DOI] [PubMed] [Google Scholar]
- 6.Chandrashekar P., Fender E.A., Al-Hijji M.A., et al. Novel use of MitraClip for severe mitral regurgitation due to infective endocarditis. J Invasive Cardiol. 2017;29(2):E21–E22. [PubMed] [Google Scholar]
- 7.Santos-Martinez S., Alkhodair A., Nombela-Franco L., et al. Transcatheter aortic valve replacement for residual lesion of the aortic valve following “Healed” infective endocarditis. JACC Cardiovas Interv. 2020;13(17):1983–1996. doi: 10.1016/j.jcin.2020.05.033. [DOI] [PubMed] [Google Scholar]
- 8.Brankovic M., Ansari J., Karanam R., Waxman S. Transcatheter aortic valve replacement as a rescue treatment for prosthetic valve endocarditis. JACC Case Rep. 2022;4(19):1306–1310. doi: 10.1016/j.jaccas.2022.04.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.El Sabbagh A., Yucel E., Zlotnick D., et al. Percutaneous mechanical aspiration in infective endocarditis: applications, technical considerations, and future directions. J Soc Cardiovasc Angiogr Interv. 2024;3(4) doi: 10.1016/j.jscai.2023.101269. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Holst K., Becker T., Magruder J.T., et al. Beyond static planning: computational predictive modeling to avoid coronary artery occlusion in TAVR. Ann Thorac Surg. 2025;119(1):145–151. doi: 10.1016/j.athoracsur.2024.05.041. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Transthoracic Echocardiography of Aortic Valve
Parasternal long and apical 5-chamber views showing severe aortic stenosis/insufficiency with corresponding continuous wave Doppler.
Transthoracic Echocardiography of Mitral Vegetation
Apical 4-chamber views of mitral vegetation with and without color Doppler.
Transesophageal Echocardiography of Mitral Vegetation
Mid-esophageal views of mitral vegetation with and without color Dopper.
Transesophageal Echocardiography of Aortic Valve
Mid-esophageal view of subaortic membrane and aortic valve.
Transesophageal Echocardiography of Aspiration Procedure
AngioVac funnel is steered toward vegetation, engaging and aspirating it.
Echocardiography of MR
(A) Preoperative transthoracic echocardiography of MR. (B) Intraoperative transesophageal echocardiography of MR before aspiration. (C) Postoperative transthoracic echocardiography of MR. (D) Intraoperative transesophageal echocardiography of MR after aspiration. MR = mitral regurgitation.
Fluoroscopy of TAVR Deployment
Baseline aortography, TAVR positioning, TAVR deployment, and final aortography. TAVR = transcatheter aortic valve replacement.
Transesophageal Echocardiography of TAVR Deployment
Baseline (upper left), deployment (upper right), postdeployment (lower left), and continuous wave Doppler.