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Review
. 2024 Feb 20;3(4):101269.
doi: 10.1016/j.jscai.2023.101269. eCollection 2024 Apr.

Percutaneous Mechanical Aspiration in Infective Endocarditis: Applications, Technical Considerations, and Future Directions

Abdallah El Sabbagh  1 , Evin Yucel  2 , David Zlotnick  3 , John M Moriarty  4 , Stephanie Younes  5 , Nadira Hamid  6 , Yasir Akhtar  7 , Larry M Baddour  8 , Patrick O'Gara  9 , Christoph Starck  10 , Sripal Bangalore  11 , Sahil A Parikh  12 , Kenneth Rosenfield  2 , Sanjum S Sethi  12
Affiliations
Review

Percutaneous Mechanical Aspiration in Infective Endocarditis: Applications, Technical Considerations, and Future Directions

Abdallah El Sabbagh et al. J Soc Cardiovasc Angiogr Interv. .

Abstract

In recent years, there has been a shift in the epidemiology of patients with infective endocarditis (IE). This has been characterized by an alarming increase in IE in patients who inject drugs, cardiac implantable electronic device-related IE, and those with comorbid conditions and high surgical risk. This unmet need has mandated a reevaluation of complex management strategies in these patients and introduction of unconventional approaches in treatment. Percutaneous mechanical aspiration has emerged as both a diagnostic and therapeutic option in selected patients with IE. In this review, the authors discuss the gaps in care of IE, rationale, device armamentarium, procedural, and technical considerations and applications of percutaneous mechanical aspiration in IE.

Keywords: cardiovascular implantable electronic device; endocarditis; injection drug use; outcomes; percutaneous mechanical aspiration; tricuspid valve.

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Conflict of interest statement

David Zlotnick is on the speaker’s bureau for Abiomed, Inari Medical. John Moriarty consults for AngioDynamics, Penumbra Medical, Innova Vascular, Pavmed, Pfizer, and Boston Scientific. Nadira Hamid consults for Abbott Structural, Anteris, AMX, 4C Medical Technologies, Alleviant Medical, Edwards Lifesciences, Philips, GE, Valcare Med, VDyne, and WL Gore. Yasir Akhtar received honoraria and is on speaker bureau for AngioDynamics and Penumbra. Kenneth Rosenfield consults for and/or is on the scientific advisory board member for Althea Medical, AngioDynamics, Boston Scientific, Contego, InspireMD, Magneto, Mayo Clinic, Neptune Medical, Philips, Summa Therapeutics, SurModics, Thrombolex, Terumo, and Truvic; holds equity in Accolade, Access Vascular, Aerami, Althea Medical, Contego, Cruzar Systems, Embolitech, Endospan, InspireMD, JanaCare, Magneto, Orchestra BioMed, PQ Bypass, Prosomnus, Shockwave Medical, Summa Therapeutics, Thrombolex, Truvic, and Valcare; and is a board member for National PERT Consortium. Christoph Starck received honoraria, consults for, and is on the advisory board of AngioDynamics, Abiomed, Atricure, Medtronic, Spectranetics, Biotronik, LivaNova (Sorin), and Cook Medical and received departmental or institutional research funding from Cook Medical and Hylomorph. Sripal Bangalore is on the advisory board for Abbott Vascular, Boston Scientific, Biotronik, Amgen, Pfizer, Merck, REATA, Inari Medical, and Truvic. Sahil Parikh receives institutional grants/research support from Abbott Vascular, Shockwave Medical, TriReme Medical, SurModics, Silk Road Medical, and the National Institutes of Health; has received consulting fees from Terumo and Abiomed; and has served on the advisory boards of Abbott, Medtronic, Boston Scientific, CSI, Janssen, and Philips. Sanjum Sethi reports honoraria from Janssen and Chiesi. Abdallah Sabbagh, Evin Yucel, Stephanie Younes, Larry Baddour, and Patrick O’Gara reported no financial interests.

Figures

None
Graphical abstract
Figure 1
Figure 1
Percutaneous mechanical aspiration in persistent sepsis despite antimicrobials. Patient with large tricuspid valve vegetation (A) with persistent sepsis despite antimicrobials underwent large-bore aspiration using AngioVac under fluoroscopic (B) and intracardiac echocardiography (C,D) with effective debulking (E) and resolution of the sepsis.
Figure 2
Figure 2
Percutaneous mechanical aspiration in perforated tricuspid valve. Patient with a large tricuspid valve vegetation from injection drug-use related infective endocarditis and pre-existing perforation in the base of the tricuspid valve leaflet (A) underwent transesophageal-guided large bore aspiration using AngioVac (B). Post aspiration, there was worsening tricuspid valve regurgitation from uncovering of the leaflet perforation (C). Specimen was collected and sent to pathology (D).
Figure 3
Figure 3
Percutaneous mechanical aspiration in cardiac implantable electronic device related infective endocarditis. Patient presented with recurrent pulmonary septic emboli despite antmicrobials (A, white arrows). There was a large vegetation on the right ventricular lead (B). Patient underwent percutaneous mechanical aspiration using AngioVac under transesophageal (C,D) and fluoroscopic (E) guidance, with a run of ventricular tachycardia due to a suck down event that resolved with repositioning the catheter (D). The vegetation was successfully aspirated (F) and led to safe lead extraction (G).
Figure 4
Figure 4
Percutaneous mechanical aspiration for diagnostic sampling. Patient with ambiguous echodensity on patent foramen ovale closure device (A, white arrows) underwent small-bore percutaneous mechanical aspiration using fluoroscopy (B) and intracardiac echocardiography guidance (C,D) with retrieved specimens consistent with thrombus and not infective endocarditis (E).
Central Illustration
Central Illustration
Algorithm and device selection for PMA of IE. (Left) Advantages (green) and disadvantages (red) of large-bore and small-bore PMA of IE. (Right) Suggested approach to device selection in PMA for IE. CIED, cardiac impantable electronic device; IE, infection endocarditis; IVDU, intravenous drug use; PMA, percutaneous mechanical aspiration.
Figure 5
Figure 5
Device armamentarium in percutaneous mechanical aspiration in infective endocarditis. AngioVac system (A) consists of outer and inner cannulas that are connected to a perfusion circuit and return cannula. AlphaVac (B) uses a handheld mechanism for aspiration, while Inari FlowTriever (C) uses negative pressure generated by a large syringe and has a blood return mechanism using FlowSaver. Penumbra Lightning 12 (D) uses engine-generated aspiration forces.
Figure 6
Figure 6
Intraprocedural echocardiographic imaging steps.
Figure 7
Figure 7
Establishing the AngioVac circuit. PMA, percutaneous mechanical aspiration.
Figure 8
Figure 8
Large-borePMA of a right-sided IE using AngioVac device. Large-bore PMA of right-sided IE (A) using AngioVac device. The outer cannula is first introduced (B), followed by the inner cannular (C). Circuit flow is then initiated at low speed (D), and with continuous aspiration on, the AngioVac cannula is advanced and aligned in proximity to the vegetation (E), and the flow speed is then ramped up (F), generating high aspiration forces, successfully aspirating the vegetation (G,H). IE, infectious endocarditis; PMA, percutaneous mechanical aspiration.
Figure 9
Figure 9
Small-bore PMA using Penumbra Lightning 12. (A) Once the device is introduced into the right atrium, aspiration is initiated (B), and the device is advanced until it engages and aspirates the vegetation (C). The device is then maneuvered to engage residual vegetation (D–F). PMA, percutaneous mechanical aspiration.
Figure 10
Figure 10
Percutaneous mechanical aspiration of mitral valve infectious endocarditis via transseptal route. LAA, left atrial appendage; LUPV, left upper pulmonary vein; TSP, transseptal puncture.
Figure 11
Figure 11
Balloon-assisted tracking for transseptal delivery of AngioVac cannulas. After performing a transseptal puncture and placement of a stiff wire in the left upper pulmonary vein (LUPV), a balloon septostomy is performed using 12 mm balloon (A). Following that, the AngioVac cannulas are loaded over the stiff wire and a 7 French sheath is inserted into the AngioVac inner cannula port (B), through which the 12 mm balloon is loaded and extruded through proximal cannula (C). The system is delivered into the right atrium and the balloon is inflated at low pressure (D) followed by advancement of the balloons and cannulas across the interatrial septum to remove the razor-effect from the cannulas (E,F).
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