Background:
Device related endocarditis is a relatively rare occurring pathology in patients with intracardiac implants but is associated with high mortality and morbidity. The standard of care is the extraction of the whole system and antibiotic therapy following guideline recommendations.
In approximately 50% of cases with endocarditis an operative strategy is needed. Indicative criteria for an operative therapy are vegetations bigger than ≥10mm with a high-risk of embolization, a progression infection despite adequate conservative therapy or severe valvular dysfunction resulting in acute heart failure. In patients with severe comorbidities cardiac surgery is a procedure with very high risk resulting in a group of patients classified as not operable. Especially in this subgroup therapeutic strategies are therefore limited. A minimal-invasive aspiration can be a novel non-surgical strategy for multimorbid not-operable patients with large vegetations and a high risk of embolization.
Case summary:
A 76-year-old man with recently confirmed cardiac device related infectious endocarditis presenting with fevers, dysuric complains (Dysuria, Pollakiuria) and a syncopal event in out emergency department. Transesophageal echocardiography shows large intracardiac vegetations. Blood cultures revealed Streptococcus agalactiae bacteremia. The therapeutic extraction of the CRT-System led to intracardiac retainment of a lead fragment. Due to multiple comorbidities, the patient was considered unsuitable for surgery. Therefore, TEE-guided percutaneous mechanical aspiration (PMA) was performed, resulting in successful aspiration of the tricuspid valve vegetation. The retained lead fragment was subsequently retrieved using a snare catheter. No residual vegetation or relevant tricuspid regurgitation was observed.
Outcome:
At three months follow-up patient showed no clinical, echocardiography or laboratory evidence of recurrent infection. C-reactive protein was below the limit of detection, consistent with resolved endocarditis.
Discussion:
This case demonstrates PMA combined with snare-retrieval of intracardiac foreign material may represent a minimally invasive strategy for patients that are not feasible for cardiac surgery.
