Staphylococcal tricuspid valve infective endocarditis complicated by refractory sepsis and bilateral lung abscesses successfully treated with adjunctive mechanical aspiration

Abstract

•In bulky infective vegetations, response to antibiotic therapy can be unpredictable due to the size of vegetations and distal embolization.•Early surgery is indicated in complicated staphylococcal tricuspid valve endocarditis, but is associated with substantial risk, including early prosthetic valve endocarditis•Large-bore percutaneous mechanical aspiration provides early source control and limits valve destruction and serves as destination therapy or a bridge to more definitive surgery.

Keywords: Endocarditis. Tricuspid valve insufficiency. Drug users. Substance abuse; Intravenous. Sepsis. Staphylococcus aureus.

Fig. 1

A CT pulmonary angiogram at a level below the tracheal carina showing (A) markedly dilated main and branch pulmonary arteries. Multiple filling defects are seen within the distal pulmonary arteries bilaterally (arrow heads). (B) Contrast reflux into the dilated hepatic veins (arrows) consistent with severe tricuspid regurgitation.

Fig. 2

High resolution CT of the lungs progressing from apex [C] to diaphragm [F] showing a moderate right sided pleural effusion (green asterix), multiple ring-enhancing cavitary lesions consistent with abscesses (yellow asterix) and patchy consolidation affected multiple lung segments bilaterally (red asterix).

Fig. 3

Modified mid-esophageal right ventricular inflow view showing severe tricuspid regurgitation with multiple vegetations attached to the valve leaflets [21 × 8 mm on septal leaflet and 36 × 5 mm on posterior] with a particularly large [44 × 7 mm], multi-lobulated and highly mobile vegetation attached to the anterior leaflet of the tricuspid valve (3D reconstruction).

Fig. 4

Large chunks of vegetations extracted with the AngioVac® F-180 system [I] The aspirated vegetations contained purulent debris.