A novel therapy for tricuspid valve infective endocarditis

SESSION TITLE: Cardiovascular Disease: Hearts and Bugs SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 09:40 am - 10:25 am INTRODUCTION: Right sided infective endocarditis, seen predominantly in intravenous drug users, encompasses a minority of cases but poses a significant clinical challenge. Mortality is higher in patients with ongoing Staph aureus bacteremia, septic emboli, larger vegetation burden, and poor surgical candidacy for valvular repair or replacement. Herein we present a novel approach to a patient with all of these risk factors. CASE PRESENTATION: A 23 y.o. female with ongoing IV drug use presented with arthralgias and fatigue. Physical exam revealed purulent drainage from the right foot along with right hip, left knee, and bilateral wrist tenderness. CT chest showed multiple cavitary lesions, consistent with septic emboli. CT abdomen/pelvis exposed a right pelvic sidewall abscess measuring up to 16cm. Transthoracic echo displayed a 1.6x2.5cm vegetation on the tricuspid valve. Transesophageal echo revealed a multi-lobed echodensity on the tricuspid measuring 5.1x1x1.6cm. Her clinical status unfortunately deteriorated, requiring intubation and mechanical ventilation. Blood cultures were positive for methicillin sensitive Staph aureus. Infectious disease, cardiology, cardiothoracic surgery, and orthopedic surgery were subsequently consulted. Patient was deemed a poor candidate for valvular surgery given multiple abscesses and persistent bacteremia despite broad-spectrum antimicrobial coverage and attempted drainage of the knee effusions and pelvic abscess. Interventional cardiology was consulted and, after extensive discussion with her family and obtaining informed consent, recommended vegetation debulking with the Inari FlowTriever system. Over 9cm of vegetation was successfully removed from the tricuspid valve. Blood cultures obtained a day after the procedure were sterile. Fortunately, her condition continued to improve, and she underwent debridement of the pelvic abscess and bilateral feet. Ultimately, she was successfully extubated and continues to work on rehabilitation. DISCUSSION: Prolonged IV antibiotics are the hallmark of therapy for infective endocarditis. Surgery is indicated in the case of vegetations larger than 2cm, septic emboli, recurrent bacteremia, or evidence of ongoing shock. If patients are deemed poor surgical candidates, options have previously been limited. Catheter-based interventions emerged in 2014. Their use in vegetation debulking is off-label and more novel with approximately 300 cases reported in the literature. A recent meta-analysis showed clinically successful treatment in 79.1% of patients, defined as reduction in vegetation size >50%, in-hospital survival, absence of bacteremia recurrence, and no further requirement of valvular surgery. Our case depicts an example of catheter-based interventions providing a favorable outcome in a patient who otherwise would have had high risk of morbidity and mortality. CONCLUSIONS: For patients with right sided infective endocarditis and persistent bacteremia, source control is essential. In patients who are deemed poor surgical candidates, catheter-based debulking may be a viable therapeutic option. REFERENCE #1: Chu VH, Cabell CH, Benjamin DK Jr, et al. Early predictors of in-hospital death in infective endocarditis. Circulation. 2004;109(14):1745-1749. doi:10.1161/01.CIR.0000124719.61827.7F REFERENCE #2: Mhanna M, Beran A, Al-Abdouh A, et al. AngioVac for Vegetation Debulking in Right-sided Infective Endocarditis: A Systematic Review and Meta-Analysis. Curr Probl Cardiol. 2022;47(11):101353. doi:10.1016/j.cpcardiol.2022.101353 REFERENCE #3: Wallace SM, Walton BI, Kharbanda RK, Hardy R, Wilson AP, Swanton RH. Mortality from infective endocarditis: clinical predictors of outcome. Heart. 2002;88(1):53-60. doi:10.1136/heart.88.1.53 DISCLOSURES: No relevant relationships by Nikhil Jagan No relevant relationships by Tharun Kotaru No relevant relationships by Bryce Schutte