Abstract 15603: Simultaneous Suction Debulking of a 3 Cm Lead Vegetation in the Right Ventricle During Extraction

Abstract

A 49-year-old male with a history of NICM EF 25% with dual-chamber AICD, lupus with nonbacterial endocarditis of aortic valve, IVC filter for recurrent DVT/PE presented with septic shock due to MRSA osteomyelitis and bacteremia. TTE showed 1.8 cm vegetation. The patient had idiopathic thrombocytopenic purpura, for which IVIG was administered. To avoid obligatory systemic exposure to heparin in the setting of ITP with a larger evacuation system and crossing the IVC filter with a large bore cannula, it was decided to proceed with Penumbra evacuation of lead vegetation with simultaneous laser extraction. A short 16F sheath was inserted through the right femoral vein for the procedure. A12F Medtronic Cryo Flex sheath was advanced through the IVC filter under fluoroscopy to provide steerability in the right atrium. TEE-guided Flex sheath positioned abutting the mass/vegetation. Suction only partially retrieved the mass. RA lead was removed using mechanical extraction tools via the left chest pocket. On repeat TEE evaluation, the mass/vegetation was 3 cm on the RV lead. Since we could not aspirate the mass, we used the extraction tools to peel the mass off the lead while providing simultaneous negative suction through the Penumbra cannula. The lead was successfully extracted. TEE showed no residual mass, no significant change in tricuspid regurgitation and no pericardial effusion. Mass biopsy showed calcified blood clots. The patient was discharged on IV antibiotics. Discussion: Most cases to date report using larger systems like AngioVac for extracting larger vegetations/masses with lead extraction. Aspiration tools have been shown to extract malleable masses with lesser procedural-related morbidity. Peeling and aspiration can be used concurrently to remove these masses without significant blood loss, downstream sheading and the need for systemic anticoagulation. Further technique development can benefit in removing under such challenging scenarios.