Abstract 10605: Percutaneous Debulking of Tricuspid Valve Endocarditis in Severe Covid-19 Pneumonia After Prolonged Advanced Life 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 the cases of a 48-year-old female and 39-year-old male patient hospitalized for Covid-19 pneumonia who developed ARDS and right ventricular failure, requiring VV-ECMO and Protek Duo cannulation. The female patient was decannulated from VV-ECMO after 123 days, but subsequently developed a segmental pulmonary embolism and tricuspid mass measuring 6.4 x 5.5 x 0.5 cm (fig A). After 116 days of VV-ECMO support, the male patient developed a tricuspid valve vegetation measuring 1.4 x 1.1 cm (fig B) with an adjacent right atrial component measuring 2.1 x 1.3 cm. The Inari FlowTriever system was used to percutaneously remove both the pulmonary embolism from the female patient and the tricuspid masses from both patients. Pathological examination of the mass from the female patient demonstrated Candida albicans endocarditis in the setting of Candida fungemia (fig C). Pathologic examination of the specimens from the male patient demonstrated endocarditis consistent with Pseudomonas aeruginosa in the setting of Pseudomonas bacteremia (fig D). Both patients experienced resolution of fungemia and bacteremia after percutaneous vegetation removal, and after prolonged hospital courses were discharged with supplemental oxygen. Discussion: VV-ECMO and right ventricular support devices are invasive and associated with bloodstream infection and infective endocarditis. Percutaneous debulking of valvular vegetations, associated with these right-sided indwelling catheters, may be an effective method of source control to prevent progression to valve surgery.