**3.3 Pump**

*Advanced Concepts in Endocarditis - 2021*

The current iteration of the cannula is in its third generation. It is available in either a 180- or 20-degree angled tip (**Figure 1**). The cannula itself is radiopaque with a self-expanding nitinol tip which allows for visualization under fluoroscopic imaging. The tip is funnel shaped which allows for greater contact surface area of the unwanted material and the cannula shaft supported by a flat stainless-steel coiled wire within the catheter body to support greater pushability, kink resistance, and column strength. The cannula is further supported by a slide over sheath (**Figure 2**), which allows the user to maintain the desired angle needed to engage the unwanted material.

The circuit consists of ½ inch tubing typically used for extracorporeal circulation with the use of quick connectors which allow for greater efficiency and ease of use. The quick connector are rotating adapters that allows for rotation of the cannula independently without twisting or kinking the circuit tubing. In addition, the circuit has a built in Y-Adapter with touhy insert allowing for over-the-wire capability through a working side port (**Figure 3**). This allows the user to use up to a

17 French adjunctive device alongside the cannula if needed.

**3.1 Cannula**

**3.2 Circuit**

**150**

**Figure 2.**

**Figure 1.** *AngioVac cannula.*

*AngioVac cannula with slide over sheath.*

The pump used with this system can be any off the shelf centrifugal pump. The centrifugal pump leverages negative pressure with increase in flow rates to extirpate undesirable material into the trap. Typical flow rates are around 3-4 Liters/minute. Once the material is engaged, flows will almost always come down to zero, but the negative pressure of the pump circulating allows the material to be suctioned up into the cannula and subsequently into the circuit and trap. Cavitation can occasionally occur but is well tolerated on the right side especially if the patient does not have a patent foramen ovale. When cavitation occurs, clamping the inflow and outflow and deairing the circuit is made simple due to the quick connectors.

#### **3.4 Placement**

As mentioned earlier, the AngioVac cannula can be used in the vena cava as well as the right atrium. It is not indicated for use in the pulmonary artery, but centers have used it in the right ventricle on occasion to extirpate vegetation or clot underneath the tricuspid valve. As centers have gained more experience with thromboembolism mainly in the right atrium, more centers are now using AngioVac for vegetations particularly on the tricuspid valve [32–34]. Access is obtained usually percutaneously in both femoral veins or through the right internal jugular vein and a femoral vein for a veno-venous configuration (**Figure 4**).

**Figure 4.** *AngioVac placement and configuration.*

### **3.5 Indications**

The surgical indications for TVE are less clear than that of endocarditis involving the left side of the heart. Current indications for surgery include vegetations >2 cm, evidence of septic pulmonary emboli, methicillin resistant organism, fungal infections and structural deterioration causing severe tricuspid valve regurgitation and heart failure [21]. However, given the repeat IVDU in these patients a surgical treatment is less likely to last for long due to repeat episodes of TVE. More concerning is the potential of prosthetic valve endocarditis which almost always necessitates a reoperation. Surgeons often find themselves in an ethical dilemma when patients represent needing a reoperation, especially when they have failed a second or third time. The risk of reoperation steadily increases and at some point, the risks outweigh the benefits.

**153**

*Contemporary and Evolving Treatment of Tricuspid Endocarditis*

However, a percutaneous option is more appealing due to its less invasive nature and the fact that it can be done multiple times without increasing the risk for the patient.

Although vast data for the use of percutaneous valve debulking (PTVD) is rare,

Recent data from Starck et al. in 101 patients undergoing lead extraction with vegetation showed low risk and possible survival benefit when PTVD was combined with lead extraction [35]. Extraction was performed with either mechanical, laser or traction alone in the setting of a femoral to femoral venous configuration of AngioVac. This resulted in a theoretical reduction of septic pulmonary emboli with low intraprocedural complication rate. Overall, thirty-day mortality was 3% which

RSIE is increasing particularly due to the incidence of patients with CIEDs and IVDU particularly due to the opioid epidemic (7–10). Medical management alone is these groups of patients leads to medical failure and can lead to further complications such as septic pulmonary emboli. Surgical intervention in TVE is associated with higher risk of recurrent infection, thromboembolic and bleeding complications and reoperation with valve replacement [6]. In addition, contemporary series have shown that valve repair is preferred over replacement especially in IVDUs [6, 36, 37]. In addition to current recommendations, the use of percutaneous aspirational techniques provide a unique and effective way to treat these patients. These techniques are evolving and may become standard of care involving a multidisciplinary approach and avoid the need for surgical intervention at the time of presentation and potentially allow for a greater chance of needing of having a repair rather than a replacement in patients with structural deterioration of their valve.

there are some retrospective data available. George et al., look at a review of 33 consecutive patients over 40 months who were declined traditional surgical management for TVE. Procedural success was defined as the removal of >1 cm of particulate and/or the ability to removal additional particulate. Patients were young with a vast majority being positive for IVDU (73%) with staphylococcal species being the most common causative agent. (75%). The average size of the tricuspid vegetation was 2.1 + 0.7 cm. More than 75% of patients had clearance of bacteremia within 48 hours of the procedure. Roughly 43.5% of patients however had worsening of their tricuspid regurgitation [32]. The same group also compared PTVD to valve replacement in a retrospective study which showed that the 1-year mortality was unchanged between the two cohorts, with the PTVD cohort having a shorter hospital length of stay [33]. A recent multicenter retrospective review showed at in 89 patients, 70% of patients had complete clearance of bacteremia within 48 hours of the procedure with only one patient requiring surgery for severe TR and heart failure. Surprisingly, the TR was unchanged in most patients (60%) and improved in 20% and worsened in 20%. The group of patient who had worsening of their TR were those who was on the borderline of mild–moderate and moderate–severe TR [34].

**4.1 Percutaneous valve debulking in tricuspid valve endocarditis**

*DOI: http://dx.doi.org/10.5772/intechopen.95434*

**4. Current data**

**4.2 AngioVac in CIDE**

was due to severe sepsis.

**5. Conclusion**

However, a percutaneous option is more appealing due to its less invasive nature and the fact that it can be done multiple times without increasing the risk for the patient.
