A Minimally Invasive Alternative: Percutaneous Mechanical Aspiration for Cardiac Vegetations in Pregnant Patients with Infective Endocarditis - A Case Report

Document Type

Conference Proceeding

Publication Date

5-9-2025

Abstract

In the United States, intravenous (IV) drug use rates have increased alongside the opioid epidemic. IV drug users (IVDU) are at increased risk for infective endocarditis (IE). Most cases of IE in pregnancy occur in IVDU. Maternal mortality rates are as high as 33 percent in peripartum IE. These patients are not ideal surgical candidates due to continued drug use. Percutaneous mechanical aspiration (PMA) is a therapeutic option for tricuspid valve (TV) IE. The Angiovac system received FDA breakthrough designation for the removal of right heart vegetations. Pregnant patients with IE lesions have had successful PMA using the Angiovac which requires extracorporeal membrane oxygenation (ECMO). The FlowTriever is an alternative PMA device that does not require ECMO. We describe a patient with IE who underwent debulking of a TV vegetation using the FlowTriever at 26 weeks gestation.

A 31-year-old G5P1213 pregnant IVDU presented to the hospital at 21 weeks 4 days for fevers and abdominal pain. She was diagnosed with methicillin resistant staphylococcus aureus (MRSA) bacteremia and started on Vancomycin. A transesophageal echocardiogram (TTE) revealed a 1.5 x 0.8 cm TV vegetation, trace tricuspid regurgitation (TR), and a normal ejection fraction. CT scan showed septic emboli to the lungs. After two negative blood cultures, the patient left against medical advice. She was re-admitted at 24 weeks for septic shock, MRSA bacteremia, and septic emboli to the lungs after reporting dyspnea and hemoptysis. Repeat TTE showed a 1.2 x 1.7 cm TV vegetation with new severe TR. A thoracocentesis confirmed MRSA empyema. Due to persistent bacteremia and embolic events, Infectious Diseases transitioned her to Daptomycin and Ceftaroline. Cardiothoracic surgery advised against surgery. Interventional radiology (IR) was consulted to evaluate her candidacy for PMA of the vegetation.

The patient received betamethasone for fetal lung maturity and concerns for potential preterm delivery. At 26 weeks, she underwent an uncomplicated, IR guided transfemoral venous catheterization with pulmonary arteriography and PMA of the vegetation with 50% debulking using the FlowTriever system under general anesthesia. Two days after the procedure, blood cultures were negative. She was discharged to an inpatient rehabilitation facility where she completed 6 weeks of antibiotic therapy. The patient ultimately required delivery at 35 weeks gestation after being diagnosed with a pulmonary embolism and mycotic aneurysm. Her care involved multidisciplinary collaboration with Pulmonology, Maternal Fetal Medicine, CTS, IR, and Infectious Disease. The patient underwent a robotic thoracotomy with lung decortication and left lower lobectomy by CTS on postpartum day 6. She was discharged home on Eliquis after meeting postoperative milestones.

This multidisciplinary case describes the use of the FlowTriever PMA system as a novel option for treating peripartum IE, especially when surgical intervention is not feasible. It highlights the role and ability of PMA to significantly reduce the size of TV vegetations, resulting in negative blood cultures and clinical improvement. The FlowTriever's capability to avoid ECMO is particularly beneficial in high-risk pregnancies. PMA may be considered as a minimally invasive alternative for managing IE in pregnancy, potentially lowering fetal risks and maternal mortality.

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025.
Abstract 1852

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