Nimrod Lavi, MD

Aspiration of Lead Vegetation using AngioVac to assist in Lead Extraction for Endocarditis

Background Ablation of left ventricular (LV) summit premature ventricular contractions (PVCs) can be completed via retrograde arterial approach. In cases of severe vascular tortuosity, maneuverability of procedural catheters can present challenges. Objective We report use of the left brachial artery as an access site for PVC ablation in a patient with severe vascular tortuosity due to kyphoscoliosis. Methods 66-year-old female with severe kyphoscoliosis, mitral valve prolapse, and symptomatic PVCs (32% burden) presented for initial ablation of aortomitral continuity origin PVCs. Access was obtained via the right femoral artery, using a 9fr 85 cm sheath. However, due to marked aortic tortuosity, both the mapping and ablation catheters were difficult to maneuver. Mapping of an LV outflow tract origin PVC was achieved with a Pentarray catheter, with 30msec pre-QRS and excellent pace map, however, ablation was unsuccessful due to poor contact of the ablation catheter. Results Cardiac magnetic resonance imaging was obtained for future PVC ablation planning. During repeat ablation, the PVC was mapped to the left coronary cusp and targeted via transeptal approach, however the PVC exit site changed and became unreachable. As such, we involved vascular surgery to perform a left brachial cut down. Using an 8 French 50cm sheath, the ablation catheter was advanced into the left ventricle without difficulty. The PVC was mapped to the basal anterior LV adjacent to the mitral valve, and ablation completed. Sheath was removed, vascular surgeon closed the brachial artery, and radial and ulnar arterial flow was confirmed. On follow up, the patient reported a marked improvement in symptoms and total PVC burden was < 4%. Conclusion For patients with arterial tortuosity or challenging access to the left ventricle, a brachial arterial access approach via vascular cut down may be utilized. This can improve catheter manipulation and contact leading to procedural success.

Background In cases of endocarditis involving implantable cardioverter-defibrillator (ICD) and pacemaker lead vegetations, there is a risk of embolic phenomenon during lead extraction. Objective We report two cases describing use of endovascular aspiration during lead extraction to remove intracardiac vegetations. Methods Case one is a 58-year-old female with secondary prevention dual chamber ICD who presents for lead extraction due to a 2.7cm x 1.2 cm mass on the atrial lead and tricuspid valve septal leaflet in setting of group B streptococcus bacteremia. Case two is a 48-year-old male with primary prevention dual chamber ICD who presents for lead extraction due to at 5cm x 1.7cm mass on the right ventricular lead. Given large vegetations in both cases, extraction posed a high risk of hemodynamically significant pulmonary embolus. Both patients also displayed new, severe tricuspid valve regurgitation. Results Lead extraction was planned in concert with interventional radiology-assisted endovascular aspiration. The patients underwent general anesthesia and veno-venous bypass access was established. A 26 Fr sheath was placed in the right internal jugular vein to introduce the AngioVac cannula to the superior vena cava-right atrial junction, while a 16 Fr sheath was placed in the right common femoral vein for venous return. Extracorporeal bypass was initiated, with blood and debris filtered prior to returning blood to the venous system. TEE guidance was used to direct the AngioVac catheter to the large mass, which was sequentially removed in fragments. During the procedure the patients remained hemodynamically stable with normal oxygenation. Following mass removal, the AngioVac cannula and sheath were removed, and hemostasis achieved. Laser lead extraction was then performed successfully. At the end of the procedure, tricuspid valve regurgitation improved from severe to mild. Conclusion Endovascular aspiration can be used prior to lead extraction to remove vegetation, potentially mitigating the risk of embolic events. This minimally invasive technique offers an alternative to open-heart surgery for large vegetation removal and can help reduce the risk of pulmonary embolism during lead extraction.

Background Mobile ECG recording devices have changed the way we manage and evaluate rhythm disorder. Apple watch in particularly, due to its availability, allows a fast symptom driven data recording. Objective We present a case of a patient with recurrent atrial arrhythmia, who experienced a pre syncope event in a setting of Polymorphic Ventricular Tachycardia (PMVT), managing to record the rhythm on an Apple watch while an implantable Loop recorder (ILR) failed to detect it. Methods We present a case of a 39-year-old male with a past medical history significant for symptomatic palpitations associated with lightheadedness, and tunnel vision sensations. He was found to have atrial fibrillation (Afib) and short episodes of atrial tachycardia with rapid ventricular response. To guide therapy, an ILR-II was implanted to assess the pre syncope events and his Afib burden. Arrhythmia was managed with Metoprolol and Diltiazem in a setting of no stroke risk factors. R waves recorded in the loop recorder during sinus and atrial arrhythmia were always above 0.14mv. Results In April 2023, while at rest, the patient had recurrent episodes of dizziness associated with palpitations, chest pain, and tunnel vision. As he initially couldn’t locate his ILR marker, he used his Apple watch to record the event followed by ILR annotation. The apple watch surprisingly documented a PMVT. The ILR only captured the tail end of the event, confirming this to be a PMVT followed by a short atrial tachycardia, and not noise. As the symptoms started 20-30 sec prior, we suspect that the event was much longer than documented. Conclusion The detection of this event led to a sub cutaneous defibrillator implantation. Review of the event on Apple watch explains the lack of ILR-II ability to detect it. We review and discuss possible algorithm beside morphology that can be used to automatically detect such events.

Background Traditional therapies for right heart thrombus include anticoagulation, thrombolysis, and surgical embolectomy. Limited information is available regarding endovascular thrombectomy. Objective We report the use of endovascular aspiration thrombectomy for a right atrial appendage (RAA) clot in a patient with symptomatic AFib to facilitate a rhythm control strategy. Methods A 64-year-old man with persistent AFib on anticoagulation, heart failure, hypertension, and chronic kidney disease was referred due to markedly symptomatic AFib complicated by tachycardia-induced cardiomyopathy (LVEF of 30%) after failing to maintain sinus rhythm (SR) with amiodarone. Planned Afib ablation with pulmonary vein isolation (PVI) was aborted due to an intracardiac echocardiography (ICE) finding of a mass in the RAA suspected to be a clot. This was subsequently confirmed by transesophageal echocardiography (TEE) and cardiac MRI. Hypercoagulable work-up was unrevealing. As the mass formed while the patient was on apixaban, he was switched to Coumadin. The RAA clot persisted on serial cardiac imaging at 3, 6, 12, and 15 months despite maintaining a therapeutic INR. PVI was deferred due to concern of RAA dislodgement following restoration of SR. However, after multiple presentations to the emergency room due to heart failure despite adequate rate control, we proceeded with RAA thrombectomy, followed by PVI. Results Thrombectomy was performed with ICE guidance. Bilateral femoral venous access was obtained. ICE showed a 1.6 cm mass with a narrow stalk in the antrum of the RAA. The AlphaVac aspiration catheter was advanced via a 26Fr Dryseal sheath and positioned in the RA. A steerable catheter was advanced through the aspiration catheter side port and used to direct the collection basket toward the mass under ICE imaging. Intermittent suction thrombectomy was performed leaving a small residual stalk. The specimen submitted for pathology confirmed a thrombus. Three months later, the patient underwent successful PVI. ICE imaging at the time confirmed no clot recurrence. In subsequent follow-ups, LVEF recovered and the patient had resolution of symptoms with improved functional capacity. Conclusion Right heart thrombus presents a challenging clinical dilemma. The AlphaVac system is a simplified setup for the removal of thrombi from the venous system, including the right heart, and can be used in complex situations where clot removal is required.