Abstract
Background
Infective endocarditis involving a prosthetic mitral valve carries high morbidity, especially when complicated by embolic events. Repeat surgery is often not feasible in high-risk patients.
Case Summary
An 81-year-old man with a mitral valve bioprosthesis presented with recurrent infective endocarditis due to Streptococcus mutans, with enlarging vegetations and embolic strokes. Given prohibitive surgical risk, he underwent successful percutaneous debulking using the AngioVac system via transseptal approach under transesophageal echocardiographic and fluoroscopic guidance. Long-term suppressive antibiotics were continued. At the 30-month follow-up, the valve was structurally intact with no evidence of recurrent endocarditis.
Discussion
This case highlights the utility of AngioVac debulking of left-sided prosthetic valve vegetations in nonsurgical candidates. Successful imaging-guided aspiration minimized embolic risk and preserved valve function.
Take-Home Message
Vacuum-assisted debulking with AngioVac via a transseptal approach is a viable option in high-risk patients with prosthetic mitral valve endocarditis, offering an alternative to reoperation.
Key words: echocardiography, endocarditis, mitral valve
Visual Summary
History of Presentation
An 81-year-old man presented to the emergency department with a 1-week history of bilateral hip and buttock pain, subjective fevers, fatigue, and reduced oral intake after a recent dental procedure. He denied chest pain, dyspnea, or focal neurological symptoms.
Take-Home Messages
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Vacuum-assisted debulking using the AngioVac system via a transseptal approach may be considered in select high-risk patients with left-sided prosthetic valve endocarditis.
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This technique can reduce embolic burden, preserve prosthetic valve function, and provide an alternative to high-risk redo surgery when performed with appropriate imaging guidance and cerebral protection.
On physical examination, the patient was alert and oriented. His vital signs showed low-grade fever (temperature: 37.9 °C), blood pressure of 122/68 mm Hg, heart rate of 84 beats/min, respiratory rate of 16 breaths/min, and oxygen saturation of 97% on room air. Cardiovascular examination revealed a new systolic murmur at the left lower sternal border. Pulmonary examination was unremarkable. Abdominal palpation revealed no tenderness. There was discomfort on palpation of both sacroiliac joints, with no overt joint swelling. There were no peripheral stigmata of endocarditis, such as Janeway lesions, Osler nodes, or conjunctival hemorrhages.
Initial laboratory investigations showed elevated white blood cell count, and blood cultures grew Streptococcus mutans. He was admitted with a presumed recurrence of infective endocarditis and underwent further evaluation.
Past Medical History
One year earlier, the patient had presented with fever, dyspnea, and generalized weakness, 3 weeks after a separate dental procedure. At that time, he was diagnosed with infective endocarditis caused by Enterococcus gallinarum, with persistent bacteremia and imaging evidence of splenic infarcts. Transesophageal echocardiography (TEE) had revealed a large vegetation on a prolapsed anterior mitral leaflet, with leaflet perforation and severe (4+) mitral regurgitation. Coronary angiography showed significant proximal right coronary artery disease and a high diagonal lesion. He underwent mitral valve replacement with a 33-mm St Jude Epic bioprosthesis, coronary artery bypass grafting (left internal mammary artery to first diagonal branch, saphenous vein graft to posterior descending artery), endarterectomy of the first diagonal branch, and patent foramen ovale closure. His postoperative course was complicated by hemodynamic instability and chest tube bleeding, requiring surgical re-exploration. Hemostasis was achieved, and he recovered uneventfully. He received 6 weeks of intravenous ampicillin and doxycycline, after discontinuation of gentamicin owing to vestibular toxicity and nephrotoxicity. His medical history also included type 2 diabetes mellitus, atrial flutter, and chronic obstructive pulmonary disease.
Differential Diagnosis
Given the patient's presentation and history, the differential diagnosis included recurrent infective endocarditis, osteomyelitis, spinal abscess, and noninfectious causes such as metastatic disease or vasculitis.
Investigations
Blood cultures grew S mutans. Magnetic resonance imaging of the lumbar spine showed discitis. TEE showed 8 × 3 mm vegetations on the mitral valve, with mild mitral regurgitation. While on intravenous ceftriaxone, the patient experienced 2 embolic strokes. Repeat TEE showed enlargement of the vegetation to 15 × 8 mm, with a mean transmitral gradient of 4.9 mm Hg (Figure 1, Figure 2, Figure 3, Video 1, Video 2, Video 3).
Figure 1.
TEE Midesophageal Long-Axis View (134°) Demonstrating a Large, Mobile Echodense Mass (Vegetation) Attached to the Bioprosthetic Mitral Valve
The mass prolapses into the left atrium during diastole and measures approximately 15 × 8 mm. TEE = transesophageal echocardiography.
Figure 2.
Additional TEE Midesophageal View Image
The vegetative mass is clearly seen attached to the bioprosthetic mitral valve, prolapsing into the left atrium during diastole. TEE = transesophageal echocardiography.
Figure 3.
TEE Midesophageal Biplane View (105° and 195°) of Vegetative Mass
Images again demonstrate a large, mobile, irregular echogenic mass on the prosthetic mitral valve, consistent with vegetation. TEE = transesophageal echocardiography.
Management
Given prohibitive surgical risk, a multidisciplinary team recommended percutaneous aspiration of the vegetations using the AngioVac system (Angiodynamics). Under general anesthesia with TEE and fluoroscopic guidance, transseptal access was achieved, and the AngioVac cannula was navigated into the left atrium toward the prosthetic mitral valve (Figures 4 and 5, Video 4, Video 5, Video 6, Video 7). Much of the mobile vegetations were successfully aspirated; a small residual vegetation embedded in the lateral leaflet remained (Figure 6, Video 8). The Sentinel cerebral protection device (Boston Scientific) was used. There were no procedural complications. Pathology confirmed bacterial vegetations on gross and histologic analysis (Figure 7). The patient completed a total of 10 weeks of intravenous ceftriaxone for infective endocarditis, including 4 weeks after the AngioVac procedure, and he was subsequently maintained on long-term suppressive therapy with daily oral amoxicillin.
Figure 4.
TEE During Transseptal Puncture
Image shows tenting of the interatrial septum by the transseptal needle, guided by TEE midesophageal short-axis view (approximately 50°). TEE = transesophageal echocardiography.
Figure 5.
Fluoroscopic Image Demonstrating the AngioVac Cannula Positioned Transeptally Within the Left Atrium
The aspiration funnel is directed toward the mitral bioprosthesis to facilitate debulking of the vegetative mass.
Figure 6.
Midesophageal Long-Axis View (170°) After AngioVac-Assisted Aspiration
The previously seen large mobile vegetation has been successfully debulked, with only a small residual strand visible on the prosthetic mitral valve.
Figure 7.
Gross and Histologic Analysis of the Excised Mitral Valve Vegetation
(A) Photograph of the excised mitral valve vegetation retrieved via transseptal AngioVac aspiration. The specimen measured approximately 2.0 × 1.1 × 0.3 cm, with a friable, irregular appearance consistent with infected thrombotic material. (B) Histopathologic image (hematoxylin & eosin stain) of the excised material demonstrating recent thrombus with acute inflammatory cells.
Outcome and Follow-Up
After 30 months, the patient presented with severe right-sided weakness. Imaging revealed severe intracranial atherosclerosis with segmental occlusion of the supracallosal segment of the left anterior cerebral artery. Blood cultures were negative, but given his history, TEE was performed to further exclude the possibility of endocarditis and showed a structurally intact and normally functioning mitral prosthesis without vegetations or regurgitation (Figures 8 and 9, Videos 9 and 10).
Figure 8.
TEE Midesophageal View at 0° Obtained 30 Months Postprocedure
Image shows a structurally intact and normally functioning bioprosthetic mitral valve. No residual or recurrent vegetations are seen. TEE = transesophageal echocardiography.
Figure 9.
TEE Midesophageal View at 46° Obtained 30 Months Postprocedure
Image shows a structurally intact and normally functioning bioprosthetic mitral valve. No residual or recurrent vegetations are seen. TEE = transesophageal echocardiography.
Discussion
This case demonstrates the feasibility of percutaneous vacuum-assisted debulking of vegetations on a left-sided bioprosthetic mitral valve using the AngioVac system. While AngioVac has been more commonly used for right-sided vegetations or right atrial thrombi,1 its application to left-sided prosthetic valve endocarditis remains novel and technically challenging. Prior reports have documented percutaneous aspiration of left-sided vegetations in native or aortic prosthetic valves,2 but there have been no reported cases of its use on prosthetic mitral valve endocarditis via a transseptal approach.
The procedural complexity is heightened by the need for safe transseptal access and precise maneuvering of large-bore cannulas within the left atrium near delicate prosthetic valve structures. Cerebral embolization remains a major concern in this population, especially after embolic strokes. In our case, use of the Sentinel cerebral protection device offered an additional layer of safety during aspiration.3
Alternative approaches such as transapical access have also been reported and may offer more direct exposure to the mitral apparatus, but they are more invasive and are associated with higher procedural morbidity.4,5 Other vacuum-assisted aspiration systems such as AlphaVac have demonstrated utility in treating right-sided endocarditis and reflect a growing interest in less invasive management options for selected patients.6
Experience with the AngioVac system has evolved across institutions, with a growing body of evidence supporting its safety and efficacy in complex cases involving thrombi, vegetations, and device-related infections.7 The present case builds on this foundation and illustrates how a multidisciplinary team, advanced imaging guidance, and cerebral protection can allow for successful left-sided aspiration in high-risk surgical candidates. Long-term follow-up in our patient confirmed the durability of this approach, with a structurally intact bioprosthetic mitral valve and no recurrence of endocarditis at 30 months.
To our knowledge, this is the first reported case of using AngioVac in the management of infective endocarditis involving a bioprosthetic valve. The procedure resulted in successful debulking and preservation of normal prosthetic valve function.
Conclusions
This case highlights the successful use of percutaneous AngioVac-assisted debulking of vegetations in bioprosthetic mitral valve endocarditis, offering a viable therapeutic alternative in nonsurgical candidates. This approach can reduce embolic risk, allow effective antibiotic therapy, and preserve valve function, emphasizing the importance of individualized care and innovation in the management of complex infective endocarditis.
Visual Summary.
Timeline of Case Presentation
| Time | Event |
|---|---|
| −12 mo | Dental procedure → Enterococcus gallinarum infective endocarditis → mitral valve replacement (33-mm St Jude Epic bioprosthesis), CABG ×2, D1 endarterectomy, and PFO closure |
| 0 mo | New dental procedure → Streptococcus viridans prosthetic valve endocarditis → cerebral embolic strokes, enlarging vegetations |
| +1 mo | Percutaneous AngioVac debulking of mitral vegetations via transseptal approach |
| +4 mo | Completion of 10-wk intravenous ceftriaxone course; transitioned to chronic suppressive oral amoxicillin |
| +30 mo | Presentation with right-sided weakness → diagnosed with severe intracranial atherosclerosis → TEE showed intact prosthesis, no MR, no recurrent vegetations |
CABG = coronary artery bypass graft; D1 = first diagonal branch; MR = mitral regurgitation; PFO = patent foramen ovale; TEE = transesophageal echocardiography.
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
Real-Time TEE Video Demonstrating the Large Mobile Vegetations on the Mitral Bioprosthesis, Captured From the Midesophageal View at 41°
The vegetations exhibit significant mobility with risk of embolization.
TEE With Color Doppler Showing Multiple Vegetations on the Mitral Bioprosthesis With Only Mild Mitral Regurgitation
Three-Dimensional En Face View From the Left Atrium Demonstrates Multiple Vegetations Attached to the Prosthetic Mitral Valve Leaflets, Aiding in Procedural Planning
Fluoroscopic Video Showing AngioVac Cannula Advancement Across the Interatrial Septum and Positioning in the Left Atrium During Percutaneous Vegetation Debulking
Two-Dimensional TEE Clip During the AngioVac Procedure Showing Real-Time Aspiration and Debulking of the Vegetation From the Atrial Side of the Prosthetic Mitral Valve
Two-Dimensional TEE Clip During the AngioVac Procedure Showing Real-Time Aspiration and Debulking of the Vegetation From the Atrial Side of the Prosthetic Mitral Valve
Intraprocedural 3D TEE Demonstrating Real-Time Aspiration of Bioprosthetic Mitral Valve Vegetation Using the AngioVac Cannula via Transseptal Approach
TEE With Color Doppler After Debulking Demonstrating No Mitral Regurgitation or Stenosis and Absence of Mobile Vegetations
TEE With Color Doppler at 30-Month Follow-Up Demonstrating a Structurally Intact Mitral Bioprosthesis With No Mitral Regurgitation and No Evidence of Vegetations
Three-Dimensional TEE at Follow-Up Confirming Normal Prosthetic Valve Function and Absence of Vegetations
References
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Associated Data
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Supplementary Materials
Real-Time TEE Video Demonstrating the Large Mobile Vegetations on the Mitral Bioprosthesis, Captured From the Midesophageal View at 41°
The vegetations exhibit significant mobility with risk of embolization.
TEE With Color Doppler Showing Multiple Vegetations on the Mitral Bioprosthesis With Only Mild Mitral Regurgitation
Three-Dimensional En Face View From the Left Atrium Demonstrates Multiple Vegetations Attached to the Prosthetic Mitral Valve Leaflets, Aiding in Procedural Planning
Fluoroscopic Video Showing AngioVac Cannula Advancement Across the Interatrial Septum and Positioning in the Left Atrium During Percutaneous Vegetation Debulking
Two-Dimensional TEE Clip During the AngioVac Procedure Showing Real-Time Aspiration and Debulking of the Vegetation From the Atrial Side of the Prosthetic Mitral Valve
Two-Dimensional TEE Clip During the AngioVac Procedure Showing Real-Time Aspiration and Debulking of the Vegetation From the Atrial Side of the Prosthetic Mitral Valve
Intraprocedural 3D TEE Demonstrating Real-Time Aspiration of Bioprosthetic Mitral Valve Vegetation Using the AngioVac Cannula via Transseptal Approach
TEE With Color Doppler After Debulking Demonstrating No Mitral Regurgitation or Stenosis and Absence of Mobile Vegetations
TEE With Color Doppler at 30-Month Follow-Up Demonstrating a Structurally Intact Mitral Bioprosthesis With No Mitral Regurgitation and No Evidence of Vegetations
Three-Dimensional TEE at Follow-Up Confirming Normal Prosthetic Valve Function and Absence of Vegetations