Vacuum-assisted extraction of ilio-caval and right heart masses: A 5-year single center experience

Comparison of Outcomes of Percutaneous Mechanical Aspiration vs Tricuspid Valve Surgery in Drug Use-Associated Endocarditis of the Tricuspid Valve

Background

People who inject drugs (PWID) and present with infective endocarditis (IE) of the tricuspid valve may need valve surgery due to persistent infection, heart failure, or embolic risk. Vacuum-assisted percutaneous mechanical aspiration (PMA) has been proposed as a potential option for those who cannot undergo surgery.

Methods

We queried TriNetX, a database that provides access to electronic medical record data across health care organizations, to identify PWID who had tricuspid valve IE and underwent PMA between 2016 and 2024, using diagnostic and procedure codes. Short-term procedural and clinical outcomes were compared with PWID who underwent tricuspid valve surgery.

Results

In total, 129 patients underwent the PMA procedure and 952 had valve surgery. A higher proportion of the PMA cohort was female (66% vs 57%) and of non-White race (32% vs 22.5%). At 1 month postprocedure, the surgical group had a lower rate of death (2.5% vs 7.9%, P = .001), while the PMA group had a lower risk of heart block or need for pacemaker implantation (0% vs 4%). After propensity matching between groups, these differences were not significant. At 1 year postprocedure, groups had similar rates of heart failure, tricuspid insufficiency, or offer of treatment intervention for opioid use disorder.

Conclusions

Short-term outcomes seem comparable between PMA and tricuspid valve surgery in tricuspid valve IE in PWID. Additional studies with larger cohort numbers are needed to further evaluate the difference in long-term postoperative outcomes between the groups.

A Retrospective Analysis of AngioVac Outcomes at a Tertiary Care Center

Background

The AngioVac system is a vacuum aspiration device approved for removal of right-sided cardiac thrombi. It has also been used for management of right-sided endocarditis in selected cases. Retrospective case series have reported high success rate and acceptable 30-day mortality, but there is limited data regarding outcomes beyond the immediate postoperative period. The purpose of this study is to describe our institution's experience with the AngioVac system for thrombus, vegetation, and tumor removal with a significant improvement over previously reported 1-year survival rates.

Methods

A retrospective review of AngioVac cases performed at our tertiary care center from 2016-2022 was done. From 2016-2022, 23 patients were identified, and their outcomes are described.

Results

Our review demonstrates 81.8% procedural success, 100% procedure survival, 90.9% survival to discharge, and 81.8% 30-day survival rates. One-year survival rate was 72.7%. Complications including an 18.2% rate of new vasopressor use, 54.5% rate of transfusion requirement, and 4.5% rate of acute renal failure requiring hemodialysis were identified. Intraprocedural embolization occurred in 1 case requiring venoarterial extracorporeal membrane oxygenation support and thrombectomy. One case was converted to open surgical intervention.

Conclusions

Our review further supports the safety and efficacy of minimally invasive vacuum-assisted aspiration systems beyond the immediate postoperative period in intracardiac thrombus, tumor, and right-sided infective endocarditis. Our institution's experience emphasizes a team-based approach including interventional cardiology and cardiothoracic surgery with a standardized imaging approach with transesophageal echocardiogram. Future guidelines are needed to include an algorithmic approach to intracardiac masses.

Minimally invasive procedures for right side infective endocarditis: A targeted literature review

INTRODUCTION

Right-side infective endocarditis (RSIE) is caused by microorganisms and develops into intracardiac and extracardiac complications with high in-hospital and 1-year mortality. Treatments involve antibiotic and surgical intervention. However, those presenting with extremes e.g. heart failure, or septic shock who are not ideal candidates for conventional medical therapy might benefit from minimally invasive procedures.

OBJECTIVE

This review summarizes existing observational studies that reported minimally invasive procedures to debulk vegetation due to infective endocarditis either on valve or cardiac implantable electronic devices.

METHODS

A targeted literature review was conducted to identify studies published in PubMed/MEDLINE, EMBASE, and Cochrane Central Database from January 1, 2015 to June 5, 2023. The efficacy and/or effectiveness of minimally invasive procedural interventions to debulk vegetation due to RSIE were summarized following PRISMA guidelines.

RESULTS

A total of 11 studies with 208 RSIE patients were included. There were 9 studies that assessed the effectiveness of the AngioVac system and 2 assessed the Penumbra system. Overall procedure success rate was 87.9%. Among 8 studies that reported index hospitalization, 4 studies reported no death, while the other 4 studies reported 10 deaths.

CONCLUSIONS

This study demonstrates that multiple systems can provide minimally invasive procedure options for patients with RSIE with high procedural success. However, there are mixed results regarding complications and mortality rates. Further large cohort studies or randomized clinical trials are warranted to assess and/or compare the efficacy and safety of these systems.

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.

Modified AngioVac System use With Extracorporeal Membrane Oxygenation in a Child With Fontan Thrombosis

The AngioVac System (AVS) extracts venous and pulmonary artery (PA) thrombi. We report modified use of the second-generation AVS with concurrent venoarterial extracorporeal membrane oxygenation (VA-ECMO) in a 10-year-old, 23 kg patient with failing Fontan circulation due to acute-on-chronic Fontan and PA thrombosis. Emergent femoral VA-ECMO was initiated for profound hypoxemia during cardiac catheterization. Fluoroscopy-guided thrombo-embolectomy was performed with AVS components. A two-venous limb inflow cannulation strategy was used; the AngioVac cannula (AVC) was positioned in the central PA and joined to the existing ECMO venous-limb. Thrombus extraction proceeded by clamping the ECMO venous-limb with the existing VA-ECMO centrifugal pump generating negative pressure to the AVC. Extracorporeal membrane oxygenation arterial-limb access was used for blood return. Settings to avoid cavitation were a maximal negative pressure of 100 mmHg using <3500 RPMs. To access the branch PAs, the AVC was replaced by a custom-modified 17 Fr arterial ECMO cannula. Clot retrieval was sufficient for improved clinical status enabling ECMO discontinuation within 24-hours, and discharge home 26-days later. This is the first description of successful subtotal thrombo-embolectomy with AVS components in a child with Fontan physiology concurrently supported on VA-ECMO, using one centrifugal pump. Although feasible, circuit modifications and close monitoring are required to avoid complications.

Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study

Objective

To describe our institution's experience with the AngioVac system.

Background

Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited.

Methods

Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020.

Results

Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below.

Conclusions

Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. The data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients.