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.