Percutaneous debulking of tricuspid valve endocarditis in severe COVID-19 pneumonia after prolonged venovenous extracorporeal membrane oxygenation with right-ventricular support: a case series

Abstract

Background Over the past two years, the utilization of venovenous extracorporeal membrane oxygenation (VV-ECMO) for the treatment of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) has increased. While supporting respiratory function, VV-ECMO requires large-bore indwelling venous cannulas, which risk bleeding and infections, including endocarditis. Case Summary We describe two adults hospitalized for COVID-19 pneumonia who developed ARDS and right ventricular failure, requiring VV-ECMO and ProtekDuo cannulation. After over 100 days with these devices, both patients developed tricuspid valve vegetations. Our first patient was decannulated from ECMO and discharged, but re-presented with a segmental pulmonary embolism and tricuspid mass. The Inari FlowTriver system was chosen to percutaneously remove both the tricuspid mass and pulmonary thromboembolism. Pathological examination of the mass demonstrated Candida albicans endocarditis in the setting of Candida fungemia. Our second patient developed a tricuspid valve vegetation which was also removed with the FlowTriever system. Pathologic examination demonstrated endocarditis consistent with Pseudomonas aeruginosa in the setting of Pseudomonas bacteremia. Both patients experienced resolution of fungemia and bacteremia after percutaneous vegetation removal. After ECMO decannulation and percutaneous debulking, both patients experienced prolonged hospital stays for ventilator weaning and were eventually discharged with supplemental oxygen. Discussion VV-ECMO and right ventricular support devices are invasive and create various risks, including bloodstream infection and infective endocarditis. Percutaneous debulking of valvular vegetations associated with these right-sided indwelling devices may be an effective means of infection source control. It is unclear whether prolonged use of VV-ECMO provides a mortality benefit in COVID-19 ARDS.

Refractory cor pulmonale under extracorporeal membrane oxygenation for acute respiratory distress syndrome: the role of conversion to veno-pulmonary arterial assist—a case series

“…While right-sided infective endocarditis related to conventional ECMO was not specifically documented ( 49 ), our two cases were associated with coagulase-negative Staphylococcal species, the most common organisms detected in ECMO-related bloodstream infections ( 49 ). Our findings are in accordance with a recent case series where two cases of right-sided infective endocarditis related to ProtekDuo cannula were reported ( 50 ). This potential specific complication of V-P ECMO warrants vigilant monitoring in future research.…”

Percutaneous treatment of infective right-sided endocarditis—an alternative in high-risk surgical patients?

“… 5 In the recent years and due to the Severe acute respiratory syndrome Coronavirus 2 pandemic, the use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy did increase and offered a chance of improvement for patients with therapy refractory respiratory failure. 6 The cases reported show that in patients with a high surgical risk with severe sepsis and combined pneumonia, meningitis, and endocarditis 7 or patients with complicated endocarditis following VV-ECMO therapy in the setting of coronavirus disease 2019, 8 percutaneous debulking of vegetations is an additional therapeutic option to avoid complex, high-risk surgery. 1 , 3–5 Both case reports 7 , 8 present patients with an otherwise prohibitive risk of surgical intervention which could otherwise only be treated with the use of antibiotics.…”

“… 6 The cases reported show that in patients with a high surgical risk with severe sepsis and combined pneumonia, meningitis, and endocarditis 7 or patients with complicated endocarditis following VV-ECMO therapy in the setting of coronavirus disease 2019, 8 percutaneous debulking of vegetations is an additional therapeutic option to avoid complex, high-risk surgery. 1 , 3–5 Both case reports 7 , 8 present patients with an otherwise prohibitive risk of surgical intervention which could otherwise only be treated with the use of antibiotics. 1 , 3 However, the presence of large vegetations itself is an important risk factor for a poor outcome and can result in septic embolization into the lung with the risk of further progression of sepsis.…”

“…Therefore, additional post-procedural antibiotic treatment is of paramount importance and represents a substantial part of the therapy. 1 , 3 , 9 Although this approach as described by the authors 7 , 8 further improves the treatment of patients with right heart IE, the procedure is not without risk and can result in mobilization and subsequent embolization of the vegetation to the pulmonary circulation, cardiac tamponade, and access side bleeding. In the cases presented, the authors describe a resolution of the sepsis, improvement of the patients clinical condition, and discharge from the hospital.…”

“…In the cases presented, the authors describe a resolution of the sepsis, improvement of the patients clinical condition, and discharge from the hospital. 3 , 7 , 8 There are therapeutic indications for vacuum-assisted debulking of the vegetations in patients on IDU, cardiac device-related endocarditis (mainly implantable electronic devices but also prosthetic valves and rings) as well as patients on long-term ECMO therapy with vegetations or thrombi located at the cannulae. The technique can be used for combined therapeutic and diagnostic indications in cases in which the differentiation between thrombus, vegetation or even cardiac tumour by imaging is not possible.…”