Angiovac Use in Endocarditis During Pregnancy: A Novel Approach for Recurrent Debulking of Tricuspid Infective Vegetations in a 27-Year-Old Woman in Her 22nd and 26th Weeks of Pregnancy

Abstract

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.

Percutaneous transeptal mitral valve endocarditis debulking with AngioVac aspiration system

“…Angiovac percutaneous vacuum‐assisted aspiration system has been successfully utilized to aspirate right sided (atrial, tricuspid valve or vena cava) vegetations, pulmonic valve vegetations, right atrial masses, vena cava thrombus, thrombus/vegetation of cardiac implantable electronic devices, and for aspiration of thoracic aortic mass 4–8 . Other case report and series of patients describing novel and unique use of AngioVac aspiration system in various patient subset ie; pregnant, congenital heart disease, inferior vena cava filter thrombosis and cancer related thrombosis are further listed in Table 1 9,10 . While there are no official guidelines for intended use, it is generally reserved for patients who are inoperable or at high/prohibitive surgical risk.…”

“…[4][5][6][7][8] Other case report and series of patients describing novel and unique use of AngioVac aspiration system in various patient subset ie; pregnant, congenital heart disease, inferior vena cava filter thrombosis and cancer related thrombosis are further listed in Table 1. 9,10 While there are no official guidelines for intended use, it is generally reserved for patients who are inoperable or at high/prohibitive surgical risk. The AngioVac system includes the AngioVac cannula, AngioVac circuit and is intended for use with other manufacturer's off-the shelf pump, filter, and reinfusion cannula requiring extracorporeal circulatory support for up to 6 h. There are two cannulas available with a 20°or 180°angled tip.…”

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

“…marcescens and MSSA Yoruk et al, 2020 [21] 50/M IVDU, ICD MSSA endocarditis MSSA Souka et al, 2021 [22] 27/M IVDU, RE, TV replacement with bioprosthetic valve septic shock N/A Hamilton et al, 2021 [23] 35/F IVDU, RE Fever MRSA Kashyap et al 2021 [24] 39/F IVDU Nausea, Fever N/A ELJack et al, 2021 [25] 24/F IVDU, RE Hypotension S. aureus. E chang et al [26] 22/M N/A N/A MSSA 38/M N/A N/A MSSA 34/F N/A N/A MRSA Moriarty et al 2014 [27] 62/M ICD generalized fatigue and weakness E Faecalis Malviya et al 2016 [28] 35/M N/A septic shock MSSA 28/F IVDU septic shock MRSA 58/F IVDU, Bioprosthetic TV N/A E Faecalis Ayzenbart et al 2021 [29] 27/F IVDU Lower extremity edema, palpable purpura, dyspnea, fever MRSA Krishnan et al 2021 [30] 66/M PPM Severe lumbar back pain MSSA Hosoba et al 2015 [31] 67/M History of spinal osteomyelitis Infected breast implant, gluteal cellulitis …”

“… TV vegetation N/A Significant reduction of vegetation burden Stable on d/c TV and RVOT vegetation N/A Significant reduction of vegetation burden Stable on d/c Moriarty et al 2014 [27] Vegetation 4.76 × 2.1 cm and [LVEF] of 20%. LVEF of 20% & poor surgical candidate Successful removal Stable on d/c Malviya et al 2016 [28] 4.5-cm SVC mass N/A N/A No fatality reported TEE TV vegetations on the anterior and posterior leaflets N/A N/A No fatality reported 3.2 cm TV vegetation N/A N/A No fatality reported Ayzenbart et al 2021 [29] 2.4 × 1.2 cm and 1.4 × 0.7 cm TV masses Pregnant, septic shock and MOF Recurrence of vegetations Preeclampsia caused c-section at 33 weeks. Healthy newborn.…”

Infective Endocarditis during Pregnancy—Keep It Safe and Simple!

“…It is not recommended to perform surgery under 24 weeks of pregnancy, but to postpone it until 28 weeks of gestation due to the high risk of fetal death associated with insufficient growth [ 114 ]. Intravenous systems used with extracorporeal circulation for the removal of vegetation can be used as an alternative in the case of high-risk pregnancies [ 115 ].…”