Corresponding Author
Key Words: aortic valve, echocardiography, left-sided catheterization
In this issue of JACC: Case Reports, Arnold et al1 describe a 66-year-old woman with an atrial septal defect and persistent multivalvular mass who declined surgery after a likely embolic myocardial infarction. Because aspiration alone could not detach the 2 mobile aortic lesions, a 70-W electrified snare enabled their sequential AngioVac (Angiodynamics) removal under transesophageal echocardiography guidance and cerebral embolic protection. Pathology confirmed calcified and hyalinized papillary fibroelastomas, with no neurologic complications or recurrence at 1 year.
Intracardiac mass extraction has evolved over the past decade. Right-sided AngioVac experience subsequently established mechanical aspiration of intracardiac masses and vegetations, generally as a bailout or bridge in patients too ill for surgery.2 More recently, the addition of electrosurgery has come into play with controlled laceration of both right- and left-sided lesions with simultaneous suction.3, 4, 5 Multiple cases have reported removal of papillary fibroelastomas: mitral and cordal lesions that could be removed mechanically, with cases also describing papillary fibroelastomas that required an electrified snare.6 Each case has expanded our understanding, with improvement in technique yielding successful outcomes in different scenarios.
However, compared with the surgical literature, transcatheter reports involve far fewer patients, may leave residual stalk tissue, and provide limited long-term follow-up. The risks of recurrent tumor, recurrent embolization, and late valve injury therefore remain unknown, making continued surveillance imaging essential. The limited number of reported cases and absence of long-term follow-up leave the durability and late risks of the transcatheter approach very uncertain.
Overall, with growing experience, certain key technical principles are becoming key for universal adoption.
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Multimodality imaging should define mass mobility, stalk geometry, valve function, and adjacent structures; intraprocedural imaging must confirm secure capture before energy delivery and assess the valve afterward.
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Heart-team discussion with surgical support is essential to any case, particularly when—as in this scenario—multiple left- and right-sided lesions, atrial septal defect physiology, and prior embolization must be considered together.
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Cerebral embolic protection should be considered before left-sided mass manipulation, although neither PROTECTED TAVR nor BHF PROTECT-TAVI demonstrated a reduction in overall periprocedural stroke with routine use.7,8
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Finally, these procedures should be performed at experienced, high-volume centers capable of advanced imaging, large-bore access, extracorporeal filtration, and immediate rescue from embolization, tamponade, vascular injury, or valve dysfunction.
Transcatheter electrosurgery is neither a replacement for surgery nor a routine first-line strategy. It is an off-label bailout for selected patients who are inoperable or decline surgery, particularly when aspiration alone fails. Rigorous case selection, favorable targets, and individualized heart-team review can make electrosurgery-assisted mechanical aspiration a valuable rescue for this cohort.
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.
References
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