Percutaneous Mechanical Aspiration Thrombectomy–Assisted Management of Right-Sided Infective Endocarditis During Pregnancy

Abstract

Background

Infective endocarditis in pregnancy is associated with high rates of maternal and fetal morbidity and mortality. There are no guidelines to address the management of endocarditis in pregnancy.

Case Summary

A 31-year-old woman at 19 weeks of gestation with a history of intravenous drug use presented with abdominal pain and dyspnea. She was diagnosed with infective endocarditis with a 2-cm tricuspid valve vegetation and severe regurgitation. Her blood cultures remained positive on hospital day 7 despite antibiotics, at which time she underwent mechanical aspiration thrombectomy of the vegetation.

Discussion

This minimally invasive approach allowed for significantly less time on cardiopulmonary bypass than with open surgery and minimized maternal and fetal risks. Larger series and prospective data are needed to clarify the role of mechanical aspiration thrombectomy as a potential first-line intervention for pregnant patients who are poor surgical candidates.

Take-Home Messages

1) Infective endocarditis in pregnancy, while rare, has high maternal and fetal mortality rates, and management is complicated by limited evidence and absence of pregnancy-specific guidelines and 2) open-heart surgery with cardiopulmonary bypass poses significant risks during pregnancy; mechanical aspiration thrombectomy can be an effective alternative for nonsurgical candidates.

Visual Summary

History of Presentation

A 31-year-old, G2P0010 at 19 weeks’ gestation with no previous prenatal care and a history of intravenous drug use presented to an outside hospital with shoulder and abdominal pain, dyspnea, and lower-extremity rash. Her history included one prior miscarriage and polysubstance use (tobacco, cocaine, heroin, and benzodiazepines), with last use reported 1 week earlier. She reported irregular menstrual cycles with inconsistent use of combined hormonal contraceptives; her last menstrual period was approximately 3 months prior.

On arrival, she was tachycardic (120 bpm), tachypneic (30 breaths/min), and hypoxic (SpO2 94%). Examination revealed diffuse abdominal tenderness and bilateral lower-extremity petechiae. Initial laboratory studies showed leukocytosis (white blood count 4,000/μL), anemia (hemoglobin 8.5 g/dL), and thrombocytopenia (platelet 73,000/μL). Respiratory viral panel and urinalysis were negative. A urine drug screen was positive for cocaine, benzodiazepines, and opioids. Blood cultures grew methicillin-resistant Staphylococcus aureus. Chest computed tomography demonstrated multiple cavitating and noncavitating nodules with wedge-shaped consolidation, consistent with septic emboli. At bedside in the emergency department an ultrasound dated her pregnancy at 19 weeks 5 days and showed fetal tachycardia.

The patient rapidly developed septic shock and acute hypoxic respiratory failure requiring norepinephrine, vancomycin, and piperacillin-tazobactam. She was transferred to our tertiary care center for intensive care unit co-management with maternal fetal medicine (MFM).

Initial transthoracic echocardiogram (TTE) was nondiagnostic due to poor acoustic windows. Subsequent transesophageal echocardiogram revealed a 2.0 × 0.5-cm tricuspid valve vegetation with severe tricuspid regurgitation (Figures 1 and 2). The patient was counseled by MFM on the maternal and fetal risks of morbidity and mortality related to infective endocarditis in pregnancy and the option of pregnancy termination. The patient and her partner elected to continue the pregnancy.

Figure 1.

Tricuspid Valve Vegetation Visualized on Transesophageal Echocardiogram

Tricuspid valve vegetation (arrows and dotted line measuring vegetation) on the anterior leaflet measuring approximately 2.0 cm × 0.53 cm and extending into the right atrium as seen on transesophageal echocardiogram (TEE).

Figure 2.

Tricuspid Valve Regurgitation Observed Pre- and Post-Mechanical Aspiration Thrombectomy

Severe tricuspid valve regurgitation seen on (A) pre-mechanical aspiration thrombectomy transesophageal echocardiogram with color doppler compared to (B) moderate tricuspid valve regurgitation seen on transthoracic echocardiogram (TTE) 2 days post mechanical aspiration thrombectomy.

Management

Despite escalation of antibiotics to daptomycin and cefazolin, bacteremia persisted beyond 7 days. Multidisciplinary consensus involving MFM, cardiac surgery, structural cardiology, and infectious disease favored percutaneous mechanical aspiration using a mechanical aspiration thrombectomy system to reduce cardiopulmonary bypass exposure and minimize maternal and fetal risk.

The patient underwent successful mechanical aspiration thrombectomy of the tricuspid valve vegetation (Video 1). The specimen measured 2.5 × 1.2 cm in aggregate. Pathology revealed fibrin thrombus with leukocytes; cultures were negative, likely due to preceding antibiotic therapy.

Outcome and Follow-Up

Postprocedural TTE showed thickened tricuspid leaflets, moderate regurgitation, and a small residual vegetation (Figure 3). Blood cultures became negative after hospital day 7. Her clinical status improved, and she was weaned off vasopressors and supplemental oxygen. The patient was transitioned to long-acting dalbavancin for outpatient therapy. Peer recovery was engaged to provide support for substance use recovery, and she was discharged on methadone maintenance therapy at 23 weeks and 2 days.

Figure 3.

Post-Mechanical Aspiration Thrombectomy Specimens and Echocardiographic Results

Mechanical aspiration thrombectomy system cannister with vegetation fragments measuring an aggregate 2.5 cm × 1.2 cm × 0.2 cm on the left side with the postoperative day 2 transthoracic echocardiograms (TTEs) on the right side showing thickening of the septal and anterior tricuspid valve leaflets suggestive of residual vegetation.

Follow-up was limited due to nonadherence, and the patient did not complete the recommended surveillance TTE and fetal growth sonograms. At 38 weeks and 6 days, she presented in spontaneous labor and delivered a healthy male infant (APGAR [appearance, pulse, grimace, activity, and respiration] scores of 8 and 9). The neonate required neonatal intensive care unit admission for opioid withdrawal but was discharged after successful morphine weaning.

Postpartum echocardiography showed preserved left ventricular function (ejection fraction 55%), persistently severe tricuspid regurgitation, and a residual vegetation (1.3 × 1.4 cm). Despite contraceptive counseling and ongoing efforts by peer recovery services and the high-risk obstetrics team, the patient relapsed postpartum requiring inpatient rehabilitation and did not re-establish cardiology or MFM follow-up.

Discussion

Infective endocarditis in pregnancy is rare, affecting approximately 0.006% of all pregnancies, and carries significant risks to both the mother and fetus. Reported maternal mortality ranges from 11% to 33%, while fetal mortality rate is estimated at 14%–29%.¹

In the nonpregnant population, standard management includes prolonged intravenous antibiotic therapy with surgical interventions indicated in the presence of large vegetation (>20 mm), refractory heart failure, persistent bacteremia for more than 7 days despite adequate antibiotics, recurrent embolic events, or periannular abscess formation. For patients deemed unsuitable for open valve surgery, percutaneous mechanical thrombectomy aspiration devices provide a minimally invasive alternative.²

Currently, however, there are no specific guidelines from leading obstetrics or cardiac societies including the Society for Maternal Fetal Medicine, American College of Obstetrics and Gynecology, and the American Heart Association to address management of infective endocarditis during pregnancy. As such, treatment decisions rely on extrapolation from nonpregnant populations and individualized, case-based decision-making.

Infective endocarditis during pregnancy poses major therapeutic challenges, particularly when surgical intervention is indicated. Conventional open valve surgery requires cardiopulmonary bypass, which carries substantial maternal and fetal risks, including hypoperfusion, hypoxia, and preterm labor.

A mechanical aspiration thrombectomy device offers a minimally invasive alternative. By establishing extracorporeal bypass between the femoral and jugular veins, it allows for aspiration of vegetations, with simultaneous filtration and reinfusion of blood under continuous transesophageal echocardiographic guidance. In our patient, total extracorporeal bypass time was only 9 minutes, markedly shorter than what would be expected for open surgery, thereby mitigating maternal and fetal risk. Radiation exposure was minimal at only 3.8 seconds equaling 1.22 mGy.

To date, only 5 cases of mechanical aspiration thrombectomy use during pregnancy have been described in the literature (Table 1). Although early outcomes appear promising, long-term maternal prognosis remains influenced by the high prevalence of underlying substance use and the risk of recurrent infection. Larger series and prospective data are needed to better define efficacy, optimize patient selection, and clarify the role of these devices as a potential first-line intervention for pregnant patients who are poor surgical candidates.

Table 1.

Summary of Case Reports on Mechanical Aspiration Thrombectomy of Right-Sided Infective Endocarditis in Pregnancy

First Author, Year	Year	Gestational Age at Time of Mechanical Aspiration Thrombectomy	Pregnancy Outcome	Gestational Age at Delivery	Complications
Ayzenbart et al., 20213	2021	22 weeks, 26 weeks	Cesarean section	33 weeks	Preeclampsia
Boudova et al., 20234	2023	30 weeks	Cesarean section	32 weeks	Non-reassuring fetal heart rate; preeclampsia with severe features
Anderson & Nguyen, 20255	2025	31 weeks	Cesarean section	32 weeks	Fetal growth restriction; suspected empyema
Ali et al., 20236	2023	21 weeks	Normal spontaneous vaginal delivery	Unreported	None reported
Mullinax & Givens Raymond, 20247	2024	24 weeks	Unreported	Unreported	Heart failure

Conclusions

The patient presented in this case raised a clinical dilemma in her need for intervention for infective endocarditis during pregnancy, which has significant maternal and fetal morbidity and mortality risks. A percutaneous mechanical aspiration thrombectomy device was used as a minimally invasive technique to decrease the vegetation burden and decrease risks to maternal and fetal status compared to open surgery. Further studies are needed to define the role of these devices for the management of infective endocarditis in pregnancy requiring surgical intervention.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Take-Home Messages

• •Infective endocarditis in pregnancy, while rare, has high maternal and fetal mortality, and management is complicated by limited evidence and absence of pregnancy-specific guidelines.
• •Open-heart surgery with cardiopulmonary bypass poses significant risks during pregnancy; mechanical aspiration thrombectomy can be an effective alternative for nonsurgical candidates.

Appendix

Video 1

Intraprocedural Transesophageal Echocardiogram Images Before, During, and Immediately After Mechanical Aspiration Thrombectomy of a Right-Sided Infective Endocarditis Vegetation