Infective endocarditis (IE) during pregnancy is a rare and life-threatening disease with maternal and fetal mortality rates as high as 33% and 29%, respectively. Intravenous (IV) antibiotics with or without surgical modalities are mainstays of treatment. The use of AngioVac offers a less invasive procedure for the removal of thrombi and emboli in patients with contraindications to surgery. While its use has not yet been reported or approved in pregnancy, we present a case where AngioVac was used for debulking vegetations in a patient with tricuspid endocarditis during pregnancy. CASE PRESENTATION:A 27-year-old G2P1001 woman at 21-weeks-gestation with a history of IV drug use, untreated hepatitis C, and hypertension presented to the hospital with 3 weeks of worsening lower extremity edema, palpable purpura, dyspnea, leukocytosis, and fever. Diagnostic workup revealed methicillin-resistant Staphylococcus aureus bacteremia and transthoracic echocardiography showed severe tricuspid valve regurgitation with two vegetations of 2.4 x 1.2 cm and 1.4 x 0.7 cm. Although she met surgical criteria, she was a poor surgical candidate due to septic shock and multi-organ failure. Despite medical management, her symptoms persisted, and she developed pulmonary septic emboli, hemoptysis, and sacroiliitis. Alternatively, the patient was offered an AngioVac procedure at 22 weeks and subsequently at 26 weeks for decompensation with recurrence of valve vegetations. This allowed for nonoperative treatment of her endocarditis and delivery at 33 weeks via cesarean section for superimposed preeclampsia. Apgar scores were 7 and 8 at 1 and 5 minutes, respectively. Newborn's weight was 2000 grams. DISCUSSION:In IE during pregnancy, surgical management is generally avoided due to maternal/fetal morbidity and mortality. Unfortunately, our patient failed medical therapy and surgery carried an unacceptable risk. Current guidelines do not address IE in pregnancy. This may be due to the low incidence or reporting bias. The use of AngioVac proved beneficial. The debulking of vegetations on two occasions reduced the bacterial inoculum, thereby enhancing antibiotic therapy, gaining time for fetal maturation, and allowing the patient to survive to successful delivery. AngioVac device has been described for the treatment of right-sided endocarditis with vegetations, mainly through case reports in experienced centers, but not in pregnancy. This case carried significant challenges and a multidisciplinary discussion and strategy were key in optimizing patient and fetal outcomes.CONCLUSIONS: AngioVac debulking of IE vegetations is a novel approach and was safely used in our pregnant patient. Multidisciplinary discussion and strategy are imperative in the management of IE during pregnancy. More data is needed to widely establish the use of AngioVac in pregnancy.

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The current treatment paradigm for right sided infective endocarditis is rapidly evolving. The existing recommendations for right sided infective endocarditis include medical therapy with surgical therapy used in certain situations. Surgical therapy is based on the size of the vegetation, presence of infective complications and certain causative organisms as well the retention of intracardiac devices. Unfortunately, medical therapy alone is usually not enough to clear the infection, especially when intravenous drug use is associated as the etiology. Intravenous drug use is associated with a high rate of recidivism in tricuspid valve endocarditis. Even with indications for surgery, these patients present an ethical dilemma as most of these patients will re-infect their valves post-surgery. This often provides little option than for the surgeon to re-operate in a setting with a higher risk of mortality and morbidity. We present an evolving technique of percutaneous extirpation of vegetation, allowing for rapid clearance of endocarditis, less chance of failure of medical therapy with a lower risk profile for complication.

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