Abstract
In patients with refractory mitral valve endocarditis who are not surgical candidates, percutaneous debulking is a potential treatment option. We describe the first report of percutaneous mechanical aspiration of prosthetic mechanical mitral valve endocarditis using the AngioVac system and cerebral protection devices.
Key Words: infective endocarditis, mechanical aspiration, mitral valve
Graphical Abstract
History of Presentation
A 63-year-old woman with a past medical history significant for mechanical mitral valve replacement in 1999 and who is receiving long-term warfarin therapy presented to the emergency department with complaints of left-side weakness. Her international normalized ratio was 4.1. Computed tomography (CT) of her head showed an acute right intracerebral hemorrhage (ICH) measuring 4.5 × 4.8 × 4.4 cm with a midline shift measuring 0.4 cm (Figure 1). Her anticoagulation was reversed with prothrombin complex concentrate, and intravenous levetiracetam (Keppra, UCB, Inc) was administered. She underwent minimally invasive right-sided keyhole craniotomy with evacuation of the right parietal ICH, withholding anticoagulation for 2 weeks as per neurosurgical recommendations.
Learning Objectives
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To review the role of a multidisciplinary heart and brain team in the management and evaluation of mechanical mitral prosthesis complications.
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To describe the step-by-step technique for percutaneous aspiration of endocarditis from a mechanical mitral prosthesis.
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To identify clinical and procedural considerations during mechanical mitral prosthesis interventions.
Figure 1.
Acute Right-Side Parietooccipital Intracerebral Hemorrhage
The patient initially recuperated well during recovery; however, on day 8 she was found with new aphasia and right-sided weakness. A CT head scan showed a new acute left-sided ICH measuring 2.6 × 4.0 × 4.0 cm (Figure 2). The patient’s prior right parietal craniotomy site was stable with no evidence of new hematoma in the right cerebral hemisphere. She emergently underwent minimally invasive left craniotomy with evacuation of the left parietal ICH.
Figure 2.
Acute Left-Side Frontoparietal Intracerebral Hemorrhage
Differential Diagnosis
The in-depth multidisciplinary heart and brain team consultations included consultations from the infectious disease team; the presence of multiple ICH in different locations of the brain raised the suspicion for a thromboembolic infectious process. Blood cultures drawn grew Enterococcus faecalis. A bedside transthoracic echocardiogram demonstrated a mass on the mechanical mitral valve prosthesis (Figure 3). Transesophageal echocardiogram (TEE) demonstrated a large fluctuant mass measuring 12.1 × 5.7 mm on the mechanical mitral leaflets with highly mobile components (Video 1, Video 2, Video 3). She was started on ceftriaxone and ampicillin. Blood cultures 2 days after initiation of antibiotics were negative. She was extubated on postoperative day 4 after the left craniotomy.
Figure 3.
Transesophageal Echocardiogram Demonstrating Prosthetic Mechanical Mitral Valve Vegetation
Investigation and Decision Making
Multidisciplinary discussions were held between infectious disease, neurology, neurosurgery, cardiothoracic surgery, and the structural heart team. The patient was deemed to be too high risk for bleeding in order to perform an urgent reoperative mitral valve replacement, with the risks of cardiac surgery outweighing the benefit. The team recommended waiting for a minimum of 6 weeks before cardiac surgery could be considered. However, she remained at a heightened risk of a recurrent cerebrovascular accident due to the mechanical valve endocarditis with no signs of resolution on repeat imaging.
All options including redo-surgery, medical therapy, and off-label percutaneous mechanical mitral valve aspiration were evaluated and discussed with the patient and family by the multidisciplinary heart team. The decision was made to proceed with percutaneous mechanical aspiration. Neurosurgery recommended a minimum waiting period of 7 days after the craniotomy before performing transcatheter aspiration due to the need for intraprocedural anticoagulation.
Intervention
The patient was brought to the hybrid operating room on postoperative day 11 and was placed under general anesthesia. Under ultrasound guidance, the right radial artery was cannulated, and a 6-F sheath was placed. A sentinel cerebral protection device (CPD) was advanced through the right radial sheath and manipulated under fluoroscopic guidance with the distal basket placed in the brachiocephalic artery on the right and the left common carotid artery.
Under ultrasound guidance, the left common femoral vein (CFV) was cannulated, and a 17-F reinfusion cannula was placed under fluoroscopic guidance with its tip in the inferior vena cava. Under ultrasound guidance, the right CFV was cannulated.
Transseptal left heart catheterization was performed with a VersaCross sheath (Boston Scientific). Heparin was administered immediately after to obtain activated clotting time levels of >300 seconds. Atrial septostomy was performed with a 12 × 40 Evercross Peripheral Balloon (Medtronic) (Figure 4). The right CFV tract was dilated, and a 26-F dry seal sheath (W.L. Gore & Associates) was inserted. The F-22 AngioVac cannula (AngioDynamics) was advanced through the dry seal sheath over the guidewire and placed under fluoroscopic guidance in the left atrial chamber.
Figure 4.
Intraprocedural Interventional Transesophageal Echocardiogram Guiding Transseptal Puncture
The patient was placed on arteriovenous bypass. Under intraprocedural interventional TEE imaging and fluoroscopic guidance, the F-22 AngioVac cannula was placed near the mitral valve vegetation, and extraction of the mitral valve vegetation was performed (Figure 5, Video 4, Video 5, Video 6, Video 7). Intraprocedural interventional TEE demonstrated significant debulking of the vegetation when compared with baseline (Video 8).
Figure 5.
Intraprocedural Transesophageal Echocardiogram Images of the Mechanical Mitral Valve Endocarditis Before Aspiration
After retrieval of the AngioVac filter, the large amount of debris within the container confirmed the extraction of the mechanical mitral valve vegetation (Figure 6). Upon completion of the AngioVac procedure, interventional imaging interrogation of the mechanical mitral prosthesis demonstrated preserved mechanical leaflet function and hemodynamics (Video 9).
Figure 6.
Debris Retrieved From the Aspiration Canister
The sentinel devices were removed, and no significant debris was seen within their baskets. A Perclose (Abbott) was used to obtain hemostasis of the right and left CFV.
Follow-up Evaluation
The mechanical mitral vegetation culture returned positive for Enterococcus, but the blood cultures remained negative. The patient’s recovery course included initiation of anticoagulation 2 days after the AngioVac intervention following the recommendations of the multidisciplinary heart and brain team. Anticoagulation was initially managed with a heparin infusion, followed by a head CT which revealed stable findings. The patient was subsequently transitioned to warfarin. She was discharged 12 days after the AngioVac intervention with a plan to continue intravenous ceftriaxone, 2 g every 12 hours, and intravenous ampicillin, 2 g every 4 hours for 6 weeks.
At the 1-month outpatient clinical follow-up visit, she had had no recurrence of intracranial bleeding.
Discussion
To the best of our knowledge, this is the first case reporting percutaneous aspiration of a mechanical mitral valve vegetation. Although percutaneous aspiration of endocarditis of the tricuspid valve has been reported, there are limited data on manual aspiration of mitral valve vegetations, with only a few cases reported in the literature.1,2 The primary reason for this discrepancy is the higher risk with mitral valve aspirations given the need for a transeptal puncture and the risk of systemic embolization during the procedure. The presence of a mechanical mitral valve prosthesis adds to the complexity of the procedure with a potential risk of damage to the valve and its function.
We used CPD in our case to lower the risk of embolization. CPDs can be placed in the right brachiocephalic and left carotid artery via the right radial artery. The left vertebral artery can be protected with a CPD placed in the left subclavian artery placed from the left radial artery. This is the standard protocol that we have used for mitral valve aspirations at our center. This patient had a small diameter of the left radial artery limiting the use of a CPD in the left subclavian artery. No significant debris was noted in the CPD at the end of the procedure, and a repeat CT of the head did not show any new lesions.
Fluoroscopy and TEE should be used interprocedurally to ensure that the aspiration canula tip is in close proximity to the valve while avoiding direct contact. Given the large bore aspiration canula and aspirations at high pressure, we have noted a transient drop in the blood pressure during aspirations on the left side of the heart, so we tend to perform multiple brief 30-to 45-second runs of aspiration rather than longer runs. The AngioVac device comes with a built-in extracorporeal bypass circuit. The aspirated blood passes through the filter canister, which traps any debris, before it is reinfused to the patient via the reinfusion canula. This extracorporeal circuit also helps to prevent significant drops in the blood pressure during the procedure.
Although surgical debridement remains the standard of care for endocarditis refractory to medical therapy, there is a growing necessity for the use of percutaneous aspiration given the increasing prevalence of an aging population with higher comorbidities. Our case demonstrates the success and potential safety of the use of percutaneous mechanical aspiration in patients with a mechanical mitral valve.
Conclusions
Percutaneous aspiration of a mechanical mitral valve can be considered in patients with refractory endocarditis who are at a high surgical risk. Our case highlights the potential safety of this approach, with preserved mechanical mitral valve function at the end of the procedure.
Funding Support and Author Disclosures
The 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
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Intraprocedural interventional transesophageal echocardiogram guiding transcatheter aspiration.
AngioVac catheter engaging the mitral vegetation.
Intraprocedural transesophageal echocardiogram confirming the AngioVac funnel tip in close proximity to the vegetation during aspiration.
Intraprocedural fluoroscopy confirming position of the AngioVac catheter.
Transesophageal echocardiogram image after aspiration of the vegetation.
Three-dimensional transesophageal echocardiographic reconstruction of the mechanical mitral valve prosthesis after aspiration of the vegetation.
References
- 1.Zhang R.S., Alam U., Maqsood M.H., et al. Outcomes with percutaneous debulking of tricuspid valve endocarditis. Circ Cardiovasc Interv. 2023;16(7) doi: 10.1161/CIRCINTERVENTIONS.123.012991. [DOI] [PubMed] [Google Scholar]
- 2.Akhtar Y.N., Barry N., Foster M.T., et al. Case series of percutaneous mechanical aspiration of mitral valve endocarditis. JACC Case Rep. 2022;4(9):523–528. doi: 10.1016/j.jaccas.2022.02.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Transesophageal echocardiogram demonstrating the mechanical mitral valve vegetation.
Intraprocedural interventional transesophageal echocardiogram guiding transcatheter aspiration.
AngioVac catheter engaging the mitral vegetation.
Intraprocedural transesophageal echocardiogram confirming the AngioVac funnel tip in close proximity to the vegetation during aspiration.
Intraprocedural fluoroscopy confirming position of the AngioVac catheter.
Transesophageal echocardiogram image after aspiration of the vegetation.
Three-dimensional transesophageal echocardiographic reconstruction of the mechanical mitral valve prosthesis after aspiration of the vegetation.