Author + information
- Received June 19, 2017
- Accepted June 30, 2017
- Published online January 15, 2018.
- aDepartment of Cardiology, St. John Hospital and Medical Center, Detroit, Michigan
- bDepartment of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan
- cDepartment of Cardiac Electrophysiology, St. John Hospital and Medical Center, Detroit, Michigan
- ↵∗Address for correspondence:
Dr. Andrew Boshara, Department of Internal Medicine, St. John Hospital and Medical Center, 22101 Moross Road, Detroit, Michigan 48236.
Management of cardiac implantable electronic device−related infections involves device and percutaneous lead extraction for vegetations <3 cm (1). For larger vegetations, experts suggest open surgical removal due to the risk of embolization during percutaneous removal (1). However, this carries an exceedingly high mortality risk in hemodynamically unstable patients. We encountered a 58-year-old man with nonischemic cardiomyopathy and an implantable cardioverter-defibrillator admitted with hypotension, gram-positive bacteremia, a II/VI systolic ejection murmur at the left sternal border, and a 32-mm × 20-mm right atrial lead vegetation on transesophageal echocardiography (Figure 1). The patient underwent staged debulking of the vegetation with AngioVac (Angiodynamics, Latham, New York), a percutaneous vacuum-assisted venous drainage cannula (Figure 2), and snare using the EN Snare endovascular system (Merit Medical, South Jordan, Utah) through the right internal jugular (IJ) vein, culminating in successful removal of the vegetation (Figure 3). Upon improvement of hemodynamics, he underwent laser-assisted lead extraction the following day. Reports on the use of AngioVac for this purpose are limited. Because the natural 20° curve of the AngioVac, we feel that the IJ vein facilitates easier access to right-sided vegetations. Previous cases have described using a third, separate femoral access site for the snare device (2). However, using the snare system alongside AngioVac through the IJ vein dismisses the need for separate access sites and minimizes access-related complications. This novel approach allows for removal of large vegetations in high-risk patients, thereby obviating the need for open-heart surgery.
Dr. Hassan has speaking agreements with Zoll, Biosense Webster, Biotronic, and St Jude’s. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received June 19, 2017.
- Accepted June 30, 2017.
- 2018 American College of Cardiology Foundation