Third Year Medical Student Memorial University of Newfoundland St. John's, Newfoundland and Labrador, Canada
Case background: BACKGROUND The epidemiology of infective endocarditis (IE) has shifted dramatically, with rising incidence among younger people with substance use disorder (SUD). Approximately 5% of IE cases are drug use-associated infective endocarditis (DUA-IE), 90% of which are right-sided IE. Without addressing the underlying SUD, conventional surgical management frequently results in prosthetic valve endocarditis and recurrent infection. Recurrent drug use is the leading cause of post-operative mortality in DUA-IE.
Percutaneous mechanical aspiration (PMA) has emerged as a less invasive therapeutic alternative in high-risk IE cases. PMA is especially relevant in patients with contraindications to redo sternotomy or prosthetic reimplantation due to relapse potential. In selected patients, PMA may also serve as a bridge to surgical or addiction care by improving functional status and reducing infectious burden.
Management Challenges: PATIENT DEMOGRAPHICS A 27-year-old male, with a history of SUD on methadone, previously diagnosed with methicillin-susceptible Staphylococcus aureus tricuspid valve infective endocarditis, underwent uneventful emergent replacement of the tricuspid valve with a bioprosthetic valve (Epic Plus #33) in October 2024. Medical history includes Hepatitis C, reflux esophagitis, gastritis, hiatal hernia, ADHD, and smoking.
CLINICAL PRESENTATION The patient presented to the emergency department on April 7 2025 with a one-month history of cough, dyspnea, and generalized weakness. Physical examination revealed fever, hypoxia, and anemia, with elevated CRP, INR, and PTT. Blood cultures grew Candida spp.
DIAGNOSTIC METHODS Blood cultures were sent to Alberta Health Services Mycology Lab for further examination and confirmed the presence of Candida dubliniensis.
On April 7, a CT Chest revealed trace pleural effusions, cavitating pulmonary nodules, pulmonary emboli, retroperitoneal lymphadenopathy, and sacroiliitis. Suspicion of septic emboli. A follow-up CT Chest on April 24 showed worsening bilateral lower lobe airspace disease. Findings were consistent with ongoing septic emboli and fungal infection.
A TEE was performed on April 30 prior to PMA. The TEE revealed normal LV function, mild RV dilatation with low-normal RV systolic function. There is a large (~2.3 x 0.7 cm), highly mobile vegetation with multiple pedunculated areas attached to the bioprosthetic tricuspid valve. Moderate to severe valvular Tricuspid Regurgitation (TR) was present. There was severe tricuspid stenosis with mean gradient 11mmHg at heart rate of 101 bpm. The TEE also revealed structural degeneration of the bioprosthetic tricuspid valve and increased echogenicity of the leaflets.
TREATMENT The patient received fluconazole 400 mg PO daily for three weeks. The case was reviewed at Health Sciences Cardiovascular Rounds and the Ottawa Infective Endocarditis Rounds. The decision was made for percutaneous mechanical aspiration using the Penumbra 16-French Catheter.
The patient was consented for the procedure and on April 30, 2025, the patient underwent PMA guided by TEE and intracardiac echocardiography (ICE).
A 10-French Sheath was inserted into the Right Common Femoral Vein under ultrasound guidance and the ICE was delivered to the right atrium. The ultrasound showed that the right internal jugular was occluded at the lower distal part prior to entering the subclavian. The team decided to proceed with the femoral approach to insert the Penumbra Aspiration Device.
Another puncture in the right femoral vein above the 10-French sheath was performed using ultrasound guidance. Two Perclose devices in 30 degree fashion pre-insertion of large sheath we then inserted the Penumbra 17-French Sheath 65cm into the inferior vena cava below the right atrium. The Penumbra Flash 2.0 Catheter was inserted guided by fluoroscopy and ICE. The catheter was directed towards the tricuspid vegetation with the intention of mechanical aspiration. With multiple maneuvers and attempts, the operator removed a moderate-sized vegetation. While we were able to remove some vegetation, as it was extremely adherent to the valve, we were unsuccessful in removing it in its entirety
The femoral sheaths were removed and the Perclose sutures were tied up. The patient also needed figure 8 suture to secure the access point. The aspirated vegetation was sent for culture. The patient tolerated the procedure well, with an estimated blood loss of 400–500 mL and the patient received a one unit of packed RBCs.
A culture of the aspirated vegetation grew Candida tropicalis.
OUTCOMES The PMA was well tolerated by the patient. The procedure was successful in removing the majority of the vegetations from the leaflets of the prosthetic valve. No short term complications were reported.
Post-PMA, another TEE was performed and compared to baseline. It found similar LV and RV function to baseline, a moderate reduction (~50%) in vegetation size on the bioTVR. A vegetation of ~1.2 x 0.5 cm remains attached to the posterior valve leaflet. However, the remaining vegetation was no longer mobile/pedunculated. The moderate to severe valvular TR remained the same. The mean transvalvular tricuspid valve gradient was reduced to ~6 mmHg.
A chest x-ray performed one week post-PMA showed that the appearance has slightly improved when compared to prior. No new regions of consolidation or pleural effusion. The patient had no further septic pulmonary embolisms and oxygenations had improved to 92% on room air. The CRP was reduced and blood cultures remained negative. Five days post-PMA, the patient reported less dyspnea and improved exercise tolerance.
CONCLUSION This case highlights a novel approach using Penumbra 16 French Aspiration Catheter for successful debulking of fungal vegetation from a bioprosthetic tricuspid valve. Additionally, the case highlights the emerging role of PMA in managing fungal prosthetic valve endocarditis in DUA-IE where surgery carries significant risk. While not curative, PMA offers significant hemodynamic and symptomatic relief and may serve as a bridge to further addiction-focused care. This case supports expanding PMA indications in complex DUA-IE cases and suggests utility in fungal IE involving bioprosthetic valves.
