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Valves, Vegetations, and Valves
Keywords: aspiration, bioprosthetic valve endocarditis, right ventricular dysfunction
A 38-year-old man with congenital subaortic stenosis was treated with patch enlargement and aortic commissurotomy in infancy and aortic balloon valvuloplasty in childhood, followed by the Ross procedure at age 15. He also had a tricuspid annuloplasty ring followed by surgical bioprosthetic valve replacement (Carpentier Edwards) for severe tricuspid regurgitation. He then had a transcatheter tricuspid and pulmonic valve replacement (22-mm Melody valve in both positions) for severe tricuspid and pulmonic valve regurgitation when presented with bioprosthetic pulmonic and tricuspid valve endocarditis. Blood cultures grew Streptococcus gorgonii and transesophageal echocardiography was notable for large vegetations on the bioprosthetic tricuspid and pulmonic valves (Video 1). A 6-week course of antibiotics was given, but the patient suffered from recurrent septic pulmonary emboli as well as right ventricular (RV) dysfunction, requiring inotropes. Echocardiography was notable for residual vegetations and elevated gradients across both valves. The patient was deemed to be at excessive risk for open valve replacement. Heart transplantation was not possible due to high panel reactive antibody screen results.
Aspiration with the AngioVac system (Angiodynamics) was performed via the right internal jugular (RIJ) and large amounts of vegetation were removed from the tricuspid valve and right ventricle-to-pulmonary artery conduit (Figure 1). Blood cultures remained negative 1 month post procedure; however, gradients remained elevated across the tricuspid and pulmonic valves, with residual RV dysfunction. As such, percutaneous pulmonic valve replacement was performed with a 22 mm Melody valve via the RIJ and tricuspid valve replacement was performed with a 23-mm Sapien S3 valve (Edwards Lifesciences) (Video 2) with significant improvement in valve and RV function (Video 3). The patient was discharged several days later and was doing well at 6-month follow-up.
We present a novel method for the treatment of right-sided bioprosthetic valve endocarditis with AngioVac debulking followed by percutaneous pulmonic and tricuspid valve replacement for residual transcatheter valve degeneration and RV dysfunction.
Affiliations and Disclosures
From the University of California, San Francisco, Department of Medicine, Division of Cardiology, San Francisco, California.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted March 17, 2022.
Address for correspondence: Gregory L. Judson, MD, University of California, San Francisco, Department of Medicine, Division of Cardiology, San Francisco, CA. Email: gregory.judson@ucsf.edu
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