angiovacsystemusedforvegetationdebulkinginapatientwith...

Case ReportAngioVac SystemUsed for VegetationDebulking in a Patient withTricuspid Valve Endocarditis: A Case Report and Review ofthe Literature

HossamAbubakar,1AhmedRashed,2AhmedSubahi,1AhmedS.Yassin,1MohamedShokr,2

and Mahir Elder2

1Department of Internal Medicine, Wayne State University, Detroit, MI, USA2Department of Cardiovascular Medicine, DMC/Wayne State University, Detroit, MI, USA

Correspondence should be addressed to Hossam Abubakar; [email protected]

Received 16 August 2017; Accepted 3 October 2017; Published 7 November 2017

Academic Editor: Man-Hong Jim

Copyright © 2017HossamAbubakar et al.*is is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

AngioVac is a vacuum-based device approved in 2014 for percutaneous removal of undesirable materials from the intravascularsystem. Although numerous reports exist with regard to the use of the AngioVac device in aspiration of iliocaval, pulmonary,upper extremity, and right-sided heart chamber thrombi, very few data are present demonstrating its use in treatment of right-sided endocarditis. In this case report, we describe the novel device used in debulking a large right-sided tricuspid valve vegetationreducing the occurrence of septic embolisation and enhancing the e2cacy of antibiotics in clearance of bloodstream infection.Further research is needed in larger RSIE patient populations to con5rm the bene5ts and the potential of improved outcomesassociated with the AngioVac device as well as identify its potential complications.

1. CasePresentation andProcedureDescription

A 33-year-old female with a history of hepatitis C and activeintravenous heroin use presented to an outside facility withcomplaints of worsening shortness of breath. A transtho-racic echocardiogram (TTE) was done and showedtricuspid valve (TV) vegetation measuring 3×1.5 cm withsevere tricuspid regurgitation (TR). CT scan of the chestrevealed signs concerning septic pulmonary emboli. She wasalso found to have severe sepsis and was transferred to thecoronary care unit for further management. Blood cultureson admission yielded Streptococcus pyogenes, and she wasempirically started on vancomycin, linezolid, and cefepimeuntil organisms were shown to be pan-sensitive after whichantibiotic coverage was narrowed to penicillin G. Clindamycinwas added for synergism, given her extensive septic pul-monary emboli. Repeat blood cultures revealed the sameorganism for 3 consecutive days. Her respiratory statuscontinued to worsen, and she was consequently intubated.No source other than intravenous drug use (IVDU) was

found to be the cause of the bacteremia. Due to the size of thevegetation and persistent bacteremia despite appropriatemedical therapy, cardiothoracic surgery was consulted forthe possibility of surgical intervention, but the patient wasdeemed a poor surgical candidate due to her poor nutritionalstate and hemodynamic instability. After discussion with thefamily regarding the patient’s critically ill state and poorprognosis, a decision was made to transfer her to our facilityfor debulking of the tricuspid valve vegetation using theAngioVac system. A repeat TTE at our facility con5rmedprior 5ndings of TV vegetation measuring 3×1.5 cm andmoderate TR (Figure 1). Blood cultures repeated at ourfacility revealed no growth. *e patient was immediatelytaken to the catheterization laboratory for vegetationdebulking using the AngioVac system.

*e patient arrived in the catheterization laboratoryintubated and sedated. Bilateral femoral veins were accessedusing the modi5ed Seldinger technique. A 6-French (Fr)precision sheath was placed in the right common femoralvein, and an 8-French sheath was inserted into the left

HindawiCase Reports in CardiologyVolume 2017, Article ID 1923505, 7 pageshttps://doi.org/10.1155/2017/1923505

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common femoral vein. A 6-French sheath was inserted intothe right internal jugular vein (IJ). *e right IJ was thenprogressively dilated with escalating size sheaths and, sub-sequently, a 24-French sheath was placed over a Lunderquistwire. *e left common femoral vein sheath was escalated toa 16-French outlet sheath. *e AngioVac system was ad-vanced through the right IJ—a 24-French inlet sheath overa Wholey wire. Under transesophageal echocardiography(TEE) guidance, the system was further advanced via thesuperior vena cava and right atrium towards the TV, wherethe vegetation was then repeatedly suctioned. Two pieces ofthe vegetation were successfully extracted. *e intra-procedural TEE revealed a 50–60% reduction in the size ofthe TV vegetation (2.1 cm decrease in the longest dimension)(Figures 2 and 3). *e AngioVac system was removed, andhemostasis was achieved in both the right IJ and the leftcommon femoral venous accesses via purse-string sutures.*e patient tolerated the procedure well. Heparin was usedfor anticoagulation during the procedure.

*e patient’s condition improved, and she was extubatedon the second day after the procedure. Antibiotics therapycontinued. Subsequent blood cultures remained negative, andshe became afebrile with a steady decline in her white bloodcell count. Seven days after the AngioVac procedure, she wasdischarged to a rehabilitation facility to 5nish six weeks ofintravenous penicillin G therapy. During a follow-up ap-pointment at an infectious disease clinic one month afterhospital discharge, the patient was seen with no symptoms orsigns of reinfection.

2. Discussion

*e vast majority of cases of right-sided infective endo-carditis (RSIE) are in the intravenous drug use (IVDU)population [1]. Epidemiological studies have shown that,among IVDU patients who present with fever, 13% will haveechocardiographic evidence of IE [2] and 41% of bacteremicIVDU patients will have evidence of IE, the majority ofwhich is RSIE [3]. Clinical features are distinct from thoseof left-sided endocarditis. *e most common manifestationsare fever and sepsis in addition to symptoms related to septicpulmonary emboli including chest pain, dyspnea, cough,and hemoptysis [4]. Although the Duke criteria have their

theoretical limitations when applied in diagnosing RSIE, theyremain the most widely utilized criteria for diagnosis [4]. *eclose association of the disease to IVDU creates obstacles tosuccessful treatment. *ese challenges include nonadherenceto in-hospital treatment and noncompliance to follow-up,creating scarcity of data on long-term outcomes [1]. Despitethese challenges, RSIE is shown to have a relatively morefavorable prognosis when compared to left-sided disease withan in-hospital mortality of less than 10% [1].

Management is multidisciplinary and involves the in-volvement of a general cardiologist, an infectious diseasespecialist, a cardiac surgeon, and, occasionally, an inter-ventional cardiologist. *ere is su2cient evidence that, inuncomplicated cases of RSIE caused by Staphylococcusaureus, two weeks of antibiotic therapy is su2cient [5].Antibiotic treatment of nonstaphylococcal RSIE, as in ourcase, is analogous to that of left-sided disease and includesan extended treatment course of 4–6 weeks [6]. While in-dications of surgery for left-sided disease are well estab-lished, the role of surgery in RSIE is less clear. Nevertheless,there are complications where surgery is agreed to be rea-sonable.*ese include right heart failure secondary to severetricuspid regurgitation with poor response to medicaltherapy, sustained infection caused by di2cult-to-treat or-ganisms (i.e., fungi and multidrug-resistant bacteria) or lackof response to appropriate antimicrobial therapy, and tri-cuspid valve vegetations that are ≥ 20mm in diameter and

Figure 1: Preprocedural transthoracic echocardiogram (TTE).Apical 4-chamber view revealing a 3×1.5 cm tricuspid valvevegetation (red arrow).

Figure 2: Preprocedural transesophageal echocardiogram (TEE).Midesophageal longitudinal-axis 115-degree view revealing the tri-cuspid valve vegetation 4.2 cm in its largest diameter (red arrow).

Figure 3: Postprocedural transesophageal echocardiogram (TEE).Midesophageal short-axis 0-degree view revealing the tricuspidvalve vegetation reduced in size to 2.1 cm from its largest diameter(red arrow).

2 Case Reports in Cardiology

Tabl

e1:

Repo

rtson

theuseof

theAng

ioVac

device

intreatm

ento

fRSIE.

Autho

r/year

Type

ofpu

blication

Age/sex

Organ

ismLo

catio

nof

vegetatio

nIndicatio

nfor

procedure

Preprocedu

ral

vegetatio

nsiz

eRe

ductionin

vegetatio

nsiz

ePo

stprocedural

bacterem

ia

Tricuspid

regu

rgita

tion

(TR)

prog

ression

Outcome

Todo

ran

etal.[20]

(2011)

Caserepo

rt53

y/o,M

Haemophilus

parain"u

enzae

SVC/RA

junc

tion

Lack

ofrespon

seto

approp

riate

antim

icrobialtherap

y1.7cm

100%

remov

alRe

solved

Not

repo

rted

Improv

emen

twith

nofurther

sequ

el

Jone

setal.

[21]

(2017)

Caserepo

rt25

y/o,

FCa

ndida

albicans

(i)SV

/RA

junc

tion

attached

toIC

DRV

lead

(i)Pe

rsisten

tfun

gemia

despite

approp

riate

antim

icrobialtherap

y

SV/RA

junc

tion:

6.1cm

×1.6

5cm

Remov

alof

6cm

vegetatio

n(residua

lvegetatio

nsiz

eno

treported)

Resolved

Not

repo

rted

Improv

emen

twith

nofurther

sequ

el(ii)R

A(ii)R

ecurrent

septic

embo

liRA

:−2

.1cm

×1.6

cm

Scha

erf

etal.[10]

(2016)

Retrospective

stud

y(20

patie

nts)

Mean

age:

76±11

8coagulase-

negativ

eSA

13IC

D;

7pa

cemaker

(i)La

ckof

respon

seto

approp

riate

antim

icrobialtherap

y

Average

size:

3.6cm±1.2cm

Not

men

tione

d

Resolved

in19/20

patie

nts

Not

repo

rted

Not

repo

rted

clearly

3MSSA

4MRS

A3Streptococci

Sexno

trepo

rted

1En

terococcus

1Po

lymicrobial

(ii)B

ridg

eto

percutan

eous

lead

remov

al

*iagaraj

etal.[22]

(2017)

Caseseries

Patie

nt1:

35y/o,M

MSSA

SVC/RA

junc

tion

extend

ing

into

TV

(i)La

ckof

respon

seto

approp

riate

antim

icrobialtherap

y4.5cm

100%

remov

alRe

solved

Not

repo

rted

Improv

emen

twith

nofurther

sequ

el(ii)V

egetationsiz

e≥20

mm

Patie

nt2:

28y/o,

FMRS

ATV

(i)La

ckof

respon

seto

approp

riate

antim

icrobialtherap

y2.2×1.7cm

100%

remov

alRe

solved

Not

repo

rted

MRS

Abacterem

iarecurren

ce,

cardiaca

rrest,an

ddeath5da

yspo

stprocedure

(ii)V

egetationsiz

e≥20

mm

Patie

nt3:

53y/o,

FEn

terococcus

faecalis

Biop

rosthetic

TV

(i)Vegetationsiz

e≥20

mm

3.2cm

25–5

0%redu

ction

insiz

eRe

solved

Improv

emen

tfrom

mod

erate

tomild

Improv

emen

twith

mild

worsening

ofTR

(ii)W

orsening

ofTV

regu

rgita

tion

Case Reports in Cardiology 3

Tabl

e1:Con

tinued.

Autho

r/year

Type

ofpu

blication

Age/sex

Organ

ismLo

catio

nof

vegetatio

nIndicatio

nfor

procedure

Preprocedu

ral

vegetatio

nsiz

eRe

ductionin

vegetatio

nsiz

ePo

stprocedural

bacterem

ia

Tricuspid

regu

rgita

tion

(TR)

prog

ression

Outcome

Divekar

etal.[7]

(2013)

Caserepo

rt17

y/o,

MMSSA

Pulm

onary

valve

Recurren

tpulmon

ary

embo

lism

despite

antim

icrobialtherap

y3.5cm

×1.5cm

Sign

i5cant

redu

ction

(residua

lvegetatio

nsiz

eno

treported)

Resolved

Not

repo

rted

Clin

ical

improv

emen

twith

nofurther

sequ

el

George

etal.[23]

(2017)

Retrospective

stud

y(33

patie

nts)

Mean

age:

37±12

14MRS

A

TVLa

ckof

respon

seto

approp

riate

antim

icrobialtherap

y2.1cm±0.7cm

Average

of61%

redu

ction

insiz

e

Resolved

in28/33

patie

nts

14pa

tients:

worsening

ofTR

(3requ

ired

electiv

eTV

repa

ir)

28pa

tients:

improv

emen

twith

nofurther

sequ

el11

MSSA

12,M

3polym

icrobial

1pa

tient:

developed

postprocedural

cardiac

tampo

nade

requ

iring

pericardiocentesis

21,F

5Ca

ndida

3pa

tients:death

Makdisi

etal.[16]

(2016)

Caserepo

rt24

y/o,M

MRS

ATV

Lack

ofrespon

seto

approp

riate

antim

icrobialtherap

y

0.9cm

×0.7cm

80%

redu

ction

insiz

eRe

solved

Nochan

ge

Clin

ical

improv

emen

twith

nofurther

sequ

el0.7cm

×1cm

Pateletal.

[11]

(2013)

Caseseries

Patie

nt1:

59y/o,M

SAIC

Dlead

(i)Vegetationsiz

e≥20

mm

3cm

×2cm

Sign

i5cant

redu

ction

(residua

lvegetatio

nsiz

eno

treported)

Resolved

Improv

emen

tin

degree

ofTR

Clin

ical

improv

emen

twith

nofurther

sequ

el

(ii)B

ridg

eto

percutan

eous

lead

remov

al

Patie

nt2:

82y/o,M

Group

BStreptococcus

(i)Pa

cemaker

lead

(i)Vegetationsiz

e≥20

mm

(i)Pa

cemaker

lead

:4cm

×1.5cm

Sign

i5cant

redu

ction

(residua

lvegetatio

nsiz

eno

treported)

Not

repo

rted

Not

repo

rted

Not

repo

rted

(ii)T

V(ii)B

ridg

eto

percutan

eous

lead

remov

al

(ii)T

V:

0.5cm

×1.1

cm

Patie

nt3:

56y/o,

FMRS

APa

cemaker

lead

(i)Vegetationsiz

e≥20

mm

3.5cm

×1.7cm

Sign

i5cant

redu

ction

(residua

lvegetatio

nsiz

eno

treported)

Persisten

tbacterem

iaW

orsening

ofTR

Form

ationof

new

vegetatio

nwith

severe

TRthat

requ

ired

TVrepa

ir

(ii)B

ridg

eto

percutan

eous

lead

remov

al


Tabl

e1:Con

tinued.

Autho

r/year

Type

ofpu

blication

Age/sex

Organ

ismLo

catio

nof

vegetatio

nIndicatio

nfor

procedure

Preprocedu

ral

vegetatio

nsiz

eRe

ductionin

vegetatio

nsiz

ePo

stprocedural

bacterem

ia

Tricuspid

regu

rgita

tion

(TR)

prog

ression

Outcome

Daliaetal.

[12]

(2016)

Caserepo

rt26

y/o,

FNot

repo

rted

TVBridge

topu

lmon

ary

artery

aneurysm

repa

ir1.6cm

×0.8cm

Sign

i5cant

redu

ction

(residua

lvegetatio

nsiz

eno

treported)

Not

repo

rted

Not

repo

rted

Und

erwen

tpu

lmon

aryartery

aneurysm

repa

irsuccessfully;

clinical

improv

emen

twith

nofurther

sequ

el

Hosob

aetal.[24]

(2015)

Caseseries

Patie

nt1:

67y/o,

FMRS

ARA

Not

repo

rted

1.5cm

×1.5cm

Not

repo

rted

Resolved

Not

repo

rted

Clin

ical

improv

emen

twith

nofurther

sequ

el

Patie

nt2:

33y/o,M

Enterobacter

cloacae

RAne

arChiari

netw

ork

Not

repo

rted

2.2cm

×0.6cm

Not

repo

rted

Resolved

Not

repo

rted

Clin

ical

improv

emen

twith

nofurther

sequ

el

Patie

nt3:

70y/o,M

MSSA

SVC/RA

junc

tion

Vegetationsiz

e20

mm

3.4cm

×1.3cm

Not

repo

rted

Resolved

Not

repo

rted

Clin

ical

improv

emen

twith

nofurther

sequ

elM:m

ale,F:

female,y/o:yearso

ld,SVC:sup

eriorv

enacava,R

A:right

atrium

,ICD:implan

tablec

ardiov

erterd

e5brillator,R

V:right

ventricle,SA

:Staphylococcusa

ureus,MSSA:m

ethicillin-sensitive

Staphylococcus

aureus,M

RSA:m

ethicillin-resis

tant

Staphylococcus

aureus,T

V:tricuspid

valve,

TR:tricuspid

regu

rgita

tion.


recurrent pulmonary embolism despite antimicrobialtherapy [6]. When surgery is warranted, valve repair ratherthan replacement is preferred especially in IVDU patientsdue to the risk of recurrence of infection in prosthetic valves[6]. Our patient had a tricuspid valve vegetation with a di-ameter of >30mm, which led to the consideration of surgicalintervention. Due to the patient’s poor nutritional status,respiratory failure due to multiple septic emboli, and earlysigns of DIC, she was deemed an unsuitable candidate foropen cardiac surgery.

A noninvasive approach utilizing the AngioVac devicewas justi5ed, given our patient’s critically ill state and highperioperative risk. *e US Food and Drug Administrationapproved the AngioVac system for removal of unwantedintravascular materials (thrombi and emboli) in 2014 [7].*e device is composed of a venous drainage cannula anda reinfusion (venous return) cannula which are connected toan extracorporeal circuit and a commercially available pumphead and bubble trap. *e venous drainage component isa 22 Fr cannula with a funnel-shaped distal tip that can beadvanced through a 26 Fr sheath over a guidewire into thevenous system percutaneously. When the bypass pump isstarted, a suction force is created that facilitates aspiration ofblood and thrombotic materials into the tip of the AngioVaccannula, circulating the blood through a 5lter. After 5ltra-tion, the drained blood is returned to the patient via a secondpercutaneously placed reinfusion venous cannula throughthe internal jugular or femoral vein [8]. *is recirculation ofvenous blood minimizes intraprocedural blood loss and theneed of blood transfusion. *ere are numerous reports onthe use of the AngioVac device in aspiration of iliocaval,pulmonary, upper extremity, and right-sided heart chamberthrombi [8]. In contrast to alternative percutaneousthrombectomy devices that require prior thrombus frag-mentation and/or thrombolysis to facilitate aspiration,the AngioVac device has the advantage of aspirating thewhole intact thrombus. *is eliminates the need of pre-aspiration thrombolysis and reduces the consequent risk ofembolisation [9].

Very few data are present with regard to the use of theAngioVac device management of RSIE. *e biggest study todate by George et al. reviewed the periprocedural course of 33patients with tricuspid valve (TV) endocarditis who under-went TV vegetation debulking using the AngioVac device.Average preprocedural vegetation size was 2.1± 0.7 cm andaverage vegetation size on postprocedural echocardiographywas 0.82± 0.5 cm, demonstrating a 61% average reduction invegetation size that is in parallel to that seen in our patient. Allpatients in the study survived the procedure, and 90.9%survived the hospitalization with no further reinfection. Wesearched two literature databases (PubMed and Embase) toidentify publications reporting the use of the AngioVac devicefor treatment of RSIE (results in Table 1). Most reportedindications for the use of the AngioVac device for vegetationdebulking in RSIE are consistent with AHA proposed in-dications of surgery [6]. However, there are reports on uti-lization of the AngioVac system to debulk lead vegetations asa bridge to percutaneous lead removal in patients with car-diovascular implantable electronic device- (CIED-) related

endocarditis [10–12]. Despite data that demonstrate the safetyof percutaneous lead removal in patients with vegetations>1 cm [13], the risk of septic pulmonary embolism remainssigni5cant at 34–55% in this subset of patients [14, 15]. *ispredisposes to further infectious complications includingpulmonary abscesses and refractory sepsis. Although largepopulation data are lacking, Patel et al. proposed that theAngioVac device used for large vegetation debulking prior topercutaneous lead removal may reduce the incidence of septicpulmonary embolism in patients with CIED-related endo-carditis [11]. *e use of the novel technique has also beenreported as a bridge to reduce lag time and perioperativecomplications of cardiac surgery [7, 16]. Diminishing in-tracardiac vegetation size and the associated bacterial loadmay increase the e2cacy of antibiotics in clearing of thebloodstream infection. *is concept is supported by studiesinvestigating the e2cacy of antibiotics on diMerent bacterialinoculums [17]. High bacterial inoculums are associated withhigher antibiotic resistance and reduced penetration, a phe-nomenon known as the inoculum eMect [18]. *rough veg-etation debulking, the AngioVac allows for reduction of thebacterial inoculum and enhancement of antibiotic activity.*is hastens resolution of the septic state and consequenthemodynamic compromise which is a key determinant ofoperative and postoperative mortality associated with cardiacsurgery [19].

3. Conclusion

Our case describes a novel modality of treatment in RSIE.Although currently approved for removal of intravascularthrombi and emboli, the AngioVac device may be a prom-ising noninvasive treatment option for RSIE for a multitudeof indications. *e novel modality may be used as a sub-stitute for surgery where surgery is indicated but not possibledue to associated perioperative risk. *e device may also beutilized as a bridge to surgery and percutaneous CIED re-moval by reducing the perioperative risk through hasteningclearance of infection, improving hemodynamics, and re-ducing the risk of periprocedural septic pulmonary embo-lism. Further research is needed in larger RSIE patientpopulations to con5rm the bene5ts and the potential ofimproved outcomes associated with the AngioVac device aswell as identify its potential complications.

Conflicts of Interest

*e authors declare that there are no conNicts of interestregarding the publication of this paper.

References

[1] R. Moss and B. Munt, “Injection drug use and right sidedendocarditis,” Heart, vol. 89, no. 5, pp. 577–581, 2003.

[2] A. B. Weisse, D. R. Heller, R. J. Schimenti, R. L. Montgomery,and R. Kapila, “*e febrile parenteral drug user: a prospectivestudy in 121 patients,” American Journal of Medicine, vol. 94,no. 3, pp. 274–280, 1993.

[3] L. R. Crane, D. P. Levine, M. J. Zervos, and G. Cummings,“Bacteremia in narcotic addicts at the Detroit Medical Center.


I. Microbiology, epidemiology, risk factors, and empirictherapy,” Reviews of Infectious Diseases, vol. 8, no. 3,pp. 364–373, 1986.

[4] T. J. Cahill and B. D. Prendergast, “Infective endocarditis,”Lancet, vol. 387, no. 10021, pp. 882–893, 2016.

[5] M. J. DiNubile, “Short-course antibiotic therapy for right-sided endocarditis caused by Staphylococcus aureus ininjection drug users,” Annals of Internal Medicine, vol. 121,no. 11, pp. 873–876, 1994.

[6] L. M. Baddour, W. R. Wilson, A. S. Bayer et al., “Infectiveendocarditis in adults: diagnosis, antimicrobial therapy, andmanagement of complications: a scienti5c statement forhealthcare professionals from the American Heart Associa-tion,” Circulation, vol. 132, no. 15, pp. 1435–1486, 2015.

[7] A. A. Divekar, T. Scholz, and J. D. Fernandez, “Novel per-cutaneous transcatheter intervention for refractory activeendocarditis as a bridge to surgery-AngioVac aspirationsystem,” Catheterization and Cardiovascular Interventions,vol. 81, no. 6, pp. 1008–1012, 2013.

[8] B. Worku, A. Salemi, M. D. D’Ayala, R. F. Tranbaugh,L. N. Girardi, and I. M. Gulkarov, “*e AngioVac device:understanding the failures on the road to success,” Innova-tions, vol. 11, no. 6, pp. 430–433, 2016.

[9] S. A. Resnick, D. O’Brien, D. Strain et al., “Single-centerexperience using AngioVac with extracorporeal bypass formechanical thrombectomy of atrial and central vein thrombi,”Journal of Vascular and Interventional Radiology, vol. 27,no. 5, pp. 723–729.e1, 2016.

[10] R. H. M. Schaerf, S. Najibi, and J. Conrad, “Percutaneousvacuum-assisted thrombectomy device used for removal oflarge vegetations on infected pacemaker and de5brillatorleads as an adjunct to lead extraction,” Journal of AtrialFibrillation, vol. 9, no. 3, p. 1455, 2016.

[11] N. Patel, T. Azemi, F. Zaeem et al., “Vacuum assistedvegetation extraction for the management of large leadvegetations,” Journal of Cardiac Surgery, vol. 28, no. 3,pp. 321–324, 2013.

[12] A. A. Dalia, D. Bamira, M. Albaghdadi, M. Essandoh,K. Rosen5eld, and D. Dudzinski, “Four-dimensional trans-esophageal echocardiography-guided AngioVac debulking ofa tricuspid valve vegetation,” Journal of Cardiothoracic andVascular Anesthesia, vol. 31, no. 5, pp. 1713–1716, 2016.

[13] J. A. Grammes, C. M. Schulze, M. Al-Bataineh et al., “Percu-taneous pacemaker and implantable cardioverter-de5brillatorlead extraction in 100 patients with intracardiac vegetationsde5ned by transesophageal echocardiogram,” Journal of theAmerican College of Cardiology, vol. 55, no. 9, pp. 886–894,2010.

[14] D. Klug, D. Lacroix, C. Savoye et al., “Systemic infectionrelated to endocarditis on pacemaker leads: clinical presen-tation and management,” Circulation, vol. 95, no. 8,pp. 2098–2107, 1997.

[15] H. K. Meier-Ewert, M.-E. Gray, and R. M. John, “Endocardialpacemaker or de5brillator leads with infected vegetations:a single-center experience and consequences of transvenousextraction,” American Heart Journal, vol. 146, no. 2,pp. 339–344, 2003.

[16] G. Makdisi, T. Casciani, T. C. Wozniak, D. W. Roe, andZ. A. Hashmi, “A successful percutaneous mechanical veg-etation debulking used as a bridge to surgery in acute tricuspidvalve endocarditis,” Journal of ,oracic Disease, vol. 8, no. 1,pp. E137–E139, 2016.

[17] K. L. LaPlante and M. J. Rybak, “Impact of high-inoculumStaphylococcus aureus on the activities of nafcillin,

vancomycin, linezolid, and daptomycin, alone and in com-bination with gentamicin, in an in vitro pharmacodynamicmodel,” Antimicrobial Agents and Chemotherapy, vol. 48,no. 12, pp. 4665–4672, 2004.

[18] W. E. Rose, S. N. Leonard, K. L. Rossi, G. W. Kaatz, andM. J. Rybak, “Impact of inoculum size and heterogeneousvancomycin-intermediate Staphylococcus aureus (hVISA) onvancomycin activity and emergence of VISA in an in vitropharmacodynamic model,” Antimicrobial Agents andChemotherapy, vol. 53, no. 2, pp. 805–807, 2009.

[19] P. N. Symbas, S. E. Vlasis, L. Zacharopoulos, C. R. Hatcher Jr.,and D. Arensberg, “Immediate and long-term outlook forvalve replacement in acute bacterial endocarditis,” Annals ofSurgery, vol. 195, no. 6, pp. 721–725, 1982.

[20] T. M. Todoran, P. S. Sobieszczyk, M. S. Levy et al., “Percu-taneous extraction of right atrial mass using the AngioVacaspiration system,” Journal of Vascular and InterventionalRadiology, vol. 22, no. 9, pp. 1345–1347, 2011.

[21] B. M. Jones, O. Wazni, S. J. Rehm, and M. H. Shishehbor,“Fighting fungus with a laser and a hose:Management of a giantCandida albicans implantable cardioverter-de5brillator leadvegetation with simultaneous AngioVac aspiration and lasersheath lead extraction,” Catheterization and CardiovascularInterventions, pp. 1–4, 2017.

[22] A. K. *iagaraj, M. Malviya, W. W. Htun et al., “A novelapproach in the management of right-sided endocarditis:percutaneous vegectomy using the AngioVac cannula,”Future Cardiology, vol. 13, no. 3, pp. 211–217, 2017.

[23] B. George, A. Voelkel, J. Kotter, A. Leventhal, and J. Gurley,“A novel approach to percutaneous removal of large tricuspidvalve vegetations using suction 5ltration and veno-venousbypass: a single center experience,” Catheterization andCardiovascular Interventions, 2017.

[24] S. Hosoba, M. Mori, A. D. Furtado, and O. M. Lattouf,“Extraction of right-sided vegetation with use of an aspirationcatheter system,” Innovations, vol. 10, no. 5, pp. 357–359, 2015.


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