Simultaneous suction debulking of lead vegetation prior to percutaneous lead extraction

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis

BACKGROUND

Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown.

OBJECTIVES

To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE.

METHODS

Two independent reviewers screened abstracts and full text for inclusion and independently extracted data.

DATA SOURCES

MEDLINE, Embase, and Web of Science.

STUDY ELIGIBILITY CRITERIA

Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included.

ASSESSMENT OF RISK OF BIAS

As this was a scoping review, risk of bias assessment was not performed.

METHODS OF DATA SYNTHESIS

Descriptive data was reported.

RESULTS

We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294).

CONCLUSIONS

While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BACKGROUND

Transcatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes.

METHODS

PubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed.

RESULTS

Data from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50-85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each.

CONCLUSIONS

Transcatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Outcomes and survival of patients undergoing percutaneous vegetectomy for right heart endocarditis

Backgrounds

AngioVac is used for the percutaneous removal of vegetations and for debulking of large vegetations in patients who are not surgical candidates.This study aims to identify the demographics, echocardiographic features, indications, improvement of the tricuspid valve regurgitation, and survival outcomes of patients who have undergone AngioVac vegetectomy reported in the literature.

Methods

A systematic review was performed to identify articles reporting suction thromectomy or vegetation removal using the AngioVac system for RSIE (right sided infective endocarditis). Survival on discharge was our primary outcome. Additionally, we evaluated indications for suction thrombectomy and TR improvement. Categorical variables were expressed as percentages and ratios.

Results

A total of 49 studies were identified. The most common risk factor was intravenous drug abuse seen in 45% (20/49) and cardiovascular implantable electronic device (CIED) in 45% (20/49). Circulatory shock was seen in 35% of patients. The causative organism was gram positive cocci (86%). Moderate to severe TR was present in 74% of cases with documented echocardiograms. Indications for AngioVac were poor surgical candidacy (81%) or to reduce septic emboli risk (19%). Survival at discharge was 93%. TR improvement was reported only in 16% cases and remained unchanged/worsened in 84%.

Conclusion

AngioVac procedure is an alternative treatment for critically ill patients who cannot undergo surgery. To understand the survival, safety and candidacy of patients undergoing this procedure, further randomized control studies and literature reviews are needed. The improvement or worsening of tricuspid regurgitation in patients with TR valve involvement is another factor to be investigated.

AngioVac system guided removal of vegetations from pacemaker lead-related infective endocarditis

The AngioVac aspiration system is a catheter-based technique that has been used for removal of unwanted intravascular material in growing numbers of institutions around the world since 2013. It provides an alternative and a less invasive approach for the treatment of venous thromboembolism and intrinsic or cardiac implantable electronic devices (CIED)-related infective endocarditis. This system uses venous cannulas and extracorporeal filtering mechanisms to effectively remove thrombi or vegetations resulting in less invasion and minimal blood loss. We present a case of a woman in her mid-50s who underwent successful AngioVac-guided removal of lead vegetations followed by percutaneous CIED removal.

AngioVac for Vegetation Debulking in Right-sided Infective Endocarditis: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate the utility of AngioVac-assisted vegetation debulking (AVD) in right sided infective endocarditis (RSIE) BACKGROUND: : AngioVac is a vacuum-based device that was approved in 2014 for the percutaneous removal of undesirable materials from the intravascular system. Although there are multiple reports on the use of the AngioVac device to aspirate right-sided heart chamber thrombi, data on its use to treat RSIE is limited.

METHODS

We performed a comprehensive literature search for studies that evaluated the utility of AVD. The primary outcomes of our study were the procedural success, defined as the ability of AngioVac to produce residual vegetation size <50% (RVS<50%) without serious procedural complications, and the clinical success, defined as composite of RVS<50%, in-hospital survival, absence of recurrent bacteremia, and valve function not requiring further intervention. The secondary outcomes included the individual components of the primary outcomes and average length of hospital stay. The pooled means and proportions of our data were analyzed using random effects model, generic inverse variance method, and represented with 95% confidence intervals (CIs).

RESULTS

A total of 44 studies, including 301 patients (mean age: 44.6±18.2 years, 71.6% males) were included. Procedural success was achieved in 89.2% of patients (95% CI:82.3%-93.6%, I²=0%). Clinical success was achieved in 79.1% of patients (95%CI:67.9%-87.2%, I²=15%). Overall survival rate was 89.7% (95% CI:83.1%-93.9%%, I²=9%).

CONCLUSIONS

Our meta-analysis demonstrates that AVD is a promising therapeutic option for RSIE offering a high success rate with an acceptable complication rate across a wide range of patients.

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

The uses of implantable medical devices are safer and more common since sterilization methods and techniques were established a century ago; however, device-associated infections (DAIs) are still frequent and becoming a leading complication as the number of medical device implantations keeps increasing. This urges the world to develop instructive prevention and treatment strategies for DAIs, boosting the studies on the design of antibacterial surfaces. Every year, studies associated with DAIs yield thousands of publications, which here are categorized into four groups, i.e., antibacterial surfaces with long-term efficacy, cell-selective capability, tailored responsiveness, and immune-instructive actions. These innovations are promising in advancing the solution to DAIs; whereas most of these are normally quite preliminary “proof of concept” studies lacking exact clinical scopes. To help identify the flaws of our current antibacterial designs, clinical features of DAIs are highlighted. These include unpredictable onset, site-specific incidence, and possibly involving multiple and resistant pathogenic strains. The key point we delivered is antibacterial designs should meet the specific requirements of the primary functions defined by the “intended use” of an implantable medical device. This review intends to help comprehend the complex relationship between the device, pathogens, and the host, and figure out future directions for improving the quality of antibacterial designs and promoting clinical translations.

A Unique Case of Elizabethkingia Associated Cardiac Device Infection

Elizabethkingia is a ubiquitous gram-negative aerobic bacillus that has gained attention in recent years as an emerging nosocomial infection in critically ill patients. We describe a case of bacteremia that developed in a patient who underwent complicated surgery with an extended intensive care unit (ICU) stay. The patient underwent pacemaker extraction with laser lead extraction and treatment with intravenous antibiotics. This case illustrates the importance of lead management strategies in septic patients with cardiac implantable electronic devices (CIED).