Between a Rock and a Hard Place: Percutaneous Aspiration and Debulking for Tricuspid Valve Endocarditis

Right-sided infective endocarditis (IE) constitutes about 10% of total IE cases. Of these, tricuspid endocarditis comprises about 90% of all right-sided IE cases with intravenous drug use (IVDU) as its strongest risk factor. In patients with larger vegetations (>20 mm) or with persistent bacteremia, surgical intervention is often the standard of care. With FDA approval in 2014 and limited cases with regards to its application in tricuspid endocarditis, AngioVac (AngioDynamics, Latham, NY) has been used as a less invasive, off-label, bridging agent for tricuspid IE treatment. We present a case of a 40-year-old man with a past medical history of IVDU who presented with tricuspid endocarditis. His blood cultures were positive for methicillin-susceptible Staphylococcus aureus bacteremia. A transthoracic echocardiogram showed a 2.7 x 1.1 cm vegetation of the tricuspid valve. The patient was thought to be a poor surgical candidate for multifactorial reasons including patient preference, hemodynamic instability, and a hospital course that was complicated by septic emboli and infectious glomerulonephritis. The patient was unable to clear blood cultures despite appropriate antibiotic therapy. He subsequently underwent an AngioVac procedure with removal of the vegetation from his tricuspid valve achieving adequate source control, clear blood cultures, and resolution of endocarditis. As this case illustrates, AngioVac should be considered an effective alternative to surgical intervention in tricuspid endocarditis. Further research and awareness of the utility of AngioVac in right-sided endocarditis are warranted and should be conducted.