Abstract / Summary
Right-sided infective endocarditis (RSIE) is a difficult clinical problem, particularly among people who inject drugs (PWID), in whom large tricuspid vegetations may be complicated by severe regurgitation and septic pulmonary embolization. We describe a woman in her twenties with tricuspid valve infective endocarditis and bilateral cavitary pulmonary lesions consistent with septic emboli, in whom the vegetation enlarged from 18 × 11 mm to 18 × 20 mm and tricuspid regurgitation (TR) progressed from moderate to severe (vena contracta 12 mm, effective regurgitant orifice area 1.5 cm2, regurgitant volume 110 mL) over ten days of empirical anti-staphylococcal therapy. Surgery was considered by an individualized Heart Team assessment of the complete clinical course, but the patient declined open-heart surgery. After multidisciplinary Heart Team discussion, transesophageal echocardiography (TEE)-guided percutaneous aspiration with the AngioVac system was undertaken as an individualized debulking and source-control strategy, not as an equivalent alternative to surgery. Under general anesthesia, bilateral femoral venous access was obtained and seven aspiration passes retrieved four large vegetation fragments, with no residual intracardiac mass on completion TEE. Culture of the aspirated material yielded Serratia marcescens and Escherichia coli, neither of which was covered by the empirical regimen, which was replaced by susceptibility-guided ciprofloxacin and co-trimoxazole; ceftazidime was added when Pseudomonas aeruginosa was later isolated from blood. Residual regurgitation arose from a flail, prolapsing posterior leaflet rather than from mass effect—a finding that may reflect pre-existing infective leaflet destruction, leaflet injury during aspiration, or both—and was quantitatively reduced three to four weeks after the procedure (vena contracta 6 mm, effective regurgitant orifice area 0.55 cm2, regurgitant volume 36 mL); at six months it was moderate-to-severe and stable, with preserved right ventricular function (TAPSE 30 mm) and no recurrent vegetation. This case supports a potential diagnostic and therapeutic role for AngioVac-assisted debulking as an individualized adjunct in highly selected patients with RSIE who refuse surgery, with the caveat that aspiration reduces vegetation and embolic burden without correcting the underlying valvular lesion.