Cardiology Fellow Jacksonville, Florida, United States
Disclosure(s):
Haris Ahmed, DO: No financial relationships to disclose
Background: Tricuspid valve infective endocarditis (TVIE) may rarely present with shock. Surgery is first line with persistent bacteremia and right sided heart failure due to severe tricuspid regurgitation, however many patients are deemed poor surgical candidates. We present a patient with TVIE and mixed shock treated successfully with percutaneous vegetectomy.
Methods: Clinical
Case: A 38-year-old male with a history of active intravenous drug use was brought to the emergency department in the setting of PEA cardiac arrest. CPR was begun on arrival and ROSC was achieved after 10 minutes with multiple rounds of CPR. Post arrest transthoracic echocardiogram was remarkable for biventricular heart failure with left ventricular ejection fraction of 4% and a large vegetation on the tricuspid valve associated w/ severe tricuspid regurgitation. Bedside arterial hemodynamic monitoring with Edwards Hemosphere revealed a cardiac index of 1.4 L/min/m2 and reduced SVR. He was initially stabilized on pressor and inotrope support. Exam revealed a III/VI holosystolic murmur loudest at the left sternal border, elevated JVP and anasarca. Blood cultures were positive for Streptococcus gordonii and Haemophilus influenzae. Labs were abnormal with leukocytosis, anemia (Hgb 8.1) and thrombocytopenia (PLT 52,000).
Outcome: Decision Making: In patients with large vegetation size (>20 mm), symptoms of right heart failure and persistent bacteremia despite proper antibiotic therapy, surgical intervention is considered first line. However due to clinical instability, thrombocytopenia and recent intravenous drug abuse, Cardiothoracic surgery deemed the patient was not suitable for surgery and palliative was consulted. Despite improvement with antibiotic therapy, bacteremia and symptoms of right sided heart failure persisted. Evaluation with TEE confirmed a large tricuspid vegetation measuring 2.0 cm x 3.1 cm with severe tricuspid regurgitation. The case was discussed with the patient’s family and interventional cardiology with decision to pursue percutaneous vegetectomy as an alternative. AngioVac vegetectomy was performed with >95% debulking of the large vegetation. On hospital day 21, the patient was afebrile, off pressor support with resolution of bacteremia. The patient was eventually discharged with home antibiotics and close follow up.
Conclusion: TVIE may initially present as shock with rapid clinical deterioration. In critically ill patients with high preoperative risk, optimization for surgery is often not possible. This case underlines the use of a minimally invasive approach with AngioVac assisted vegetation debulking in large tricuspid vegetations achieving a successful outcome.
