Percutaneous Mechanical Aspiration: A Game Changer for Infective Endocarditis?

The incidence of right-sided infective endocarditis is increasing with injection drug use, indwelling lines, and device implantation. Although contemporary guidelines emphasize early referral to heart valve centres and multidisciplinary endocarditis teams, many patients who meet surgical criteria are ineligible because of prohibitive risk, clinical instability, or social complexity. Percutaneous mechanical aspiration (PMA) with the AngioVac (AngioDynamics, Latham, NY) system has emerged as a minimally invasive option to debulk infected masses, expedite bacteremia clearance, and mitigate septic embolization, particularly for large tricuspid vegetations and device-related infection; highly selected left-sided infective endocarditis cases have also been reported. AngioVac couples a large-bore aspiration cannula to a veno-venous extracorporeal circuit with continuous transesophageal echocardiography; neuroprotection is routine for left-sided targets. Across heterogeneous right-sided infective endocarditis populations, technical success approximates 85%-90%. Comparative analyses vs tricuspid surgery show broadly similar early and 1-year mortality, with shorter length of stay after PMA. Cost and length of stay signals also favour PMA in cohort studies. Adjunctive use during transvenous lead extraction facilitates the removal of bulky vegetations and might improve survival. For left-sided experience with cerebral protection, complications include embolization, bleeding and/or transfusion, vascular or intracardiac injury, and persistent and/or worsened tricuspid regurgitation; conversion to surgery is uncommon. PMA with the AngioVac might serve as a bridge to definitive therapy and expands options for otherwise inoperable patients. Evidence remains retrospective and short-term. Pragmatic, multicentre trials with core lab echocardiography, standardized success definitions, and patient-centred end points are needed to refine indications and inform guideline integration.