PO-02-081 PERCUTANEOUS REMOVAL OF LARGE VEGETATION FACILITATES SAFE TRANSCUTANEOUS LEAD EXTRACTION: A SINGLE CENTER EXPERIENCE

Abstract

Infective endocarditis (IE) is the most common indication for transvenous lead extraction (TLE), and it is associated with significant morbidity and mortality. Complete removal of the device in addition to antibiotics is required, however large vegetations (>2-3cm) on either the lead or the tricuspid valve confer a high risk of vegetation embolization with standard lead extraction. Vegetation size larger than 2cm appear to have higher incidence of intraprocedural clinically significant pulmonary embolism. An open surgical approach is usually recommended in this situation to mitigate the risk of embolization, however, surgical extraction is associated with increased morbidity/mortality and in some patients the risk is prohibitive. Percutaneous approach to remove large vegetations from tricuspid valve has been reported to be safe in several recent case reports The purpose of our study is to describe our single-center experience of the management of patients with a large vegetation involving the leads and/or the tricuspid valve. The use of percutaneous tricuspid valve/lead vegetation removal permitted or facilitated successful TLE avoiding cardiothoracic surgery We reviewed the perioperative course of 5 consecutive patients with large tricuspid valve and/or lead vegetation referred for device/lead extraction due to endocarditis. Patients with large vegetations considered at increased risk of embolization with transcutaneous extraction were referred for percutaneous vegectomy prior to TLE. Vegectomy procedure is done at our institution using the percutaneous catheter-based system FlowTriever aspiration catheter with FLEX technology (Inari Medical, Irvine, CA USA) with the guidance of intracardiac echocardiogram through femoral vein access (Figure 1). Over a 15-month period, 5 patients presented with large vegetations that precluded TLE due to embolization risk. Four patients (80%) were male, with an average age of 60 years, and the average vegetation size was 2.7 cm (2.4-3.2 cm). All patients underwent vegectomy followed by lead extraction as a staged procedure without complication. All patients survived the index hospitalization (see Table 1 for details) Percutaneous removal of large tricuspid valve/lead vegetations prior to lead extraction is a safe and effective way to manage patient with endocarditis and large vegetations thereby avoiding the morbidity and mortality associated with open heart surgeryTabled 1Table 1Patient #Age (years)Device Type# of LeadsOrganismVegetation Size (cm)Vegetation LocationComplications166CRT-D3MSSA2.5RV LeadNone263DC PPM2No growth2.4RA/RV LeadNone368CRT-D (HIS Lead)3Streptococcus2.5RA LeadNone456ICD (Dual Coil)1Corynebacterium3.0RV Lead/TVNone548DC PPM2MRSA3.2RA LeadNoneCRT-D: Cardiac resynchronization therapy – defibrillator; MSSA: Methicillin sensitive staph aureus; RV: right ventricular; DC PPM: Dual chamber permanent pacemaker; RA: right atrial; ICD: implantable cardioverter defibrillator; MRSA: Methicillin resistant staph aureus; TV: Tricuspid valve Open table in a new tab