Case Presentation and Management:
A 61-year-old male presented with 4 weeks of dyspnea on exertion, bilateral lower extremity edema and orthopnea. A dual chamber implantable cardiac defibrillator (ICD) was implanted in 2016 for the primary prevention of sudden death in the setting of non-ischemic dilated cardiomyopathy. His other co-morbidities included type 2 diabetes and chronic kidney disease. Transthoracic echocardiography revealed a mobile vegetation at the level of the tricuspid valve. Blood cultures grew Neisseria gonorrhea. Further anamnesis was negative for fever, recent travel or known high-risk exposures, abdominal pain, bleeding diathesis or genitourinary symptoms. His most recent unprotected sexual exposure was more than 1 year prior to presentation. On physical exam, a grade II/VI systolic murmur was present along with bilateral lower extremity edema and large CV waves in the jugular vein. There were no stigmata of distal embolization. Repeat blood cultures remained positive until the fourth day of hospitalization despite treatment with Vancomycin and Ceftriaxone.
The patient underwent transcatheter debulking with CIED extraction on hospital day 10.
Percutaneous debulking was performed using the Penumbra 12Fr Lightning Aspiration System (Penumbra Inc, Alameda, CA) under intra-cardiac echocardiography (ICE) guidance. The aspiration catheter was introduced through a deflectable Arctic front sheath (Medtronic Inc., Minneapolis, MN), which was within a 16-french sheath in the right femoral vein. This approach allowed for increased steerability of the aspiration system. The 16Fr outer sheath allows for the removal of the aspiration catheter and deflectable sheath en-bloc should vegetation become adherent to the aspiration sheath tip. Intracardiac echocardiography along with TEE revealed the presence of two large vegetations, one highly mobile mass adherent to both the tricuspid valve and right ventricular ICD lead (1 x 2 cm), and a second large mass (2 x 3 cm) in the right ventricular apex adherent to the right ventricular ICD lead (Figure 1). One aspiration application was required to remove the vegetation from the tricuspid valve; whereas, three aspiration applications were required to remove the vegetation adherent to the distal portion of the right ventricular lead within the right ventricle (Figure 2, supplemental video). Following transcatheter debulking, TEE and ICE confirmed the absence of any remaining mass and the CIED system was removed in total. There was no evidence of ICD pocket infection and the leads were able to be removed with gentle traction alone.
There were no immediate post-procedural complications. The patient was given a single dose of 1 gram of azithromycin and a 6-week course of intravenous ceftriaxone. He was discharged 3 days after extraction.