AngioVac debulking of a tricuspid valve mass following complex lead extraction in a rare case of Austrian syndrome: a case report

BACKGROUND: The European Society of Cardiology recommends surgical valvular intervention in right-sided infective endocarditis for persistent vegetations >20 mm after recurrent pulmonary emboli, infection with a difficult-to-eradicate organism with >7 days of persistent bacteraemia, or tricuspid regurgitation causing right-sided heart failure. In this case report, we discuss the role of percutaneous aspiration thrombectomy for a large tricuspid valve (TV) mass as an alternative to surgery due to poor surgical candidacy in a patient with Austrian syndrome, following a complex implantable cardioverter defibrillator (ICD) device extraction. CASE SUMMARY: A 70-year-old female presented to the emergency department after being found acutely delirious at home by family. Infectious workup was notable for growth of Streptococcus pneumoniae in the blood, cerebrospinal, and pleural fluid. Transoesophageal echocardiogram was pursued in the setting of bacteraemia and revealed a mobile mass on the TV consistent with endocarditis. Given the size and embolic potential of the mass and eventual need for ICD replacement, the decision was made to pursue extraction of the valvular mass. The patient was a poor candidate for invasive surgery, so we opted to perform percutaneous aspiration thrombectomy. After the ICD device was extracted, the TV mass was successfully debulked using the AngioVac system without complication. DISCUSSION: Percutaneous aspiration thrombectomy of right-sided valvular lesions has been introduced as a minimally invasive approach to avoid or delay valvular surgery. When intervention is indicated for TV endocarditis, AngioVac percutaneous thrombectomy may be a reasonable operative approach, particularly in patients who are at high risk for invasive surgery. We report a case of successful AngioVac debulking of a TV thrombus in a patient with Austrian syndrome.