Right heart large vegetations-clinical aspects and management

Abstract

Purpose: Right heart vegetations (RVH) are the serious signs of cardiac device-related infective endocarditis (CDRIE) and consists class 1 indication for transve-nous leads extraction (TLE) procedures, but large size of RVH is often considered to cardiosurgery removal. Methods: Analysis of clinical data, safety and effectiveness of TLE in 41 (mean age 66,2±12,7 years, 17 women) patients with vegetations over 2 cm was performed. This group (12,8%) was separated from 320 CDRIE consecutive patients managed with TLE in single Reference Center in years 2007-2012. Results: The clinical symptoms were nonspecific: 35 (85%) patients complained of recurrent fever, 19 (46,3%) were repeatedly hospitalized from pulmonary infection with documented pulmonary embolism in 3 (7,3%) of them. The mean time from onset of signs was 9,3±17,7 months. The vegetations measurement was performed by transthoracic echocardiography (TTE) in 36 (87,8%) patients, in remaining 5 (12,2%) the pathological structures were visible only in trans-esophageal echo (TEE). The vegetations were localized in right atrium in 30 cases (73,2%), on tricuspid valve in 6 (14,6%), in the right ventricle - in 3 (7,3%) and in vena cava superior in 2 cases (4,9%). Considering risk of TLE and open heart surgery in all pts TLE was performed and systems were removed as a whole. In 9 of them nitinol basket catheter was used for pulmonary vascular bed protection. The mean time of TLE was 122,2±56,2 min. Complete procedural success was achieved in 37 patients (90,2%), clinical success in 39 (95,1%) patients. Major complications (severe pulmonary embolism) in 2 (4,9%) patients were observed. Control examination after TLE showed the vegetation presence in 19 (46,3%) patients The in-hospital survival was 97,6% - one patient died on the next day after TLE. Conclusions: The diagnostic process of CRIE patients with the large vegetations is difficult because of nonspecific symptoms and problem with visualization despite it major sizes. TLE in patients with vegetations over 2 cm is relatively safe and effective and the TLE procedure and may to be considered as a saver option for patients with risk factors for cardiac surgery. Option of pulmonary bed protection during TLE seems to be interesting and will need dedicated tool.