Dr. Mustafa Candemir

Name of the study:
Outcomes of Percutaneous Mechanical Aspiration in Right-Sided Infective Endocarditis: The CLEAR IE Multicenter Registry

Published in Congress: TCT 2024

Link: https://www.tctmd.com/slide/outcomes-percutaneous-mechanical-aspiration-right-sided-infective-endocarditis-clear-ie

Introduction:
There has been an increase in cases of right-sided infective endocarditis (RSIE). This increase is due to drug abuse, increased use of cardiovascular implantable electronic devices, and catheter infections. Treatment options for persistent RSIE are limited, antimicrobials are inadequate, and surgery in these patients has high morbidity and mortality rates.

Objective:
This study aimed to evaluate the efficacy and safety outcomes of percutaneous mechanical aspiration (PMA) in RSIE.

Methods:
The study had a large, multicentre, retrospective, retrospective, registry-based design. Patients were recruited between January 2014 and January 2024, and their 6-week records were analyzed. The study included 256 patients with persistent RSIE who were diagnosed with infective endocarditis according to Duke criteria and for whom standard surgery was not appropriate. A 70% or ? 1 cm reduction in vegetation size was determined as procedural success. The primary efficacy was defined as culture clearance, and the primary safety point was accepted as composite outcomes in hospital mortality/ new pulmonary embolism/ emergency surgery.

Results:
Vegetation was in the right atrium in 28% (n=70) of the patients, in the right ventricle in 9.2% (n=23), and in the tricuspid valve in 68.8% (n=172). The median age of the patients was 43 years (13-87) and 42.6% (n=109) were female. The median vegetation size was 24 (0.6-90) mm and 23.2% (n=55) of these were lead vegetations. Procedural success was 89.4%, primary efficacy outcome 92.4%, and primary safety outcome 18%. 9.8% (n=25) died in hospital, 8.3% (n=21) developed new pulmonary embolism, 15. 7% (n=37) had worsening tricuspid regurgitation, 3.1% (n=8) required emergency surgery, 3.6% (n=9) had vascular access site hemorrhage, and 3.1% (n=8) had stroke. Bacterial species (OR= 9.71; 95% CI (2.27 38.24); P=0.001), absence of residual vegetation (OR= 4.35; 95% CI (1.18 25); P=0.055), immunocompetent state (OR= 3.33; 95% CI (1.01 10); P=0.032) associated with primary efficacy outcome. Device type, vegetation size, and location were not associated with primary efficacy outcomes. Primary efficacy outcome was associated with lower in-hospital mortality (OR= 0.14; 95% CI: 0.05 0.45); P=0.002). Hypoxia (OR= 3.62; 95% CI (1.87 7.17); P<0.001), shock (OR= 2.27; 95% CI (1.15 4.43); P=0.017), female (OR=2.27; 95% CI (1.19 4.55); P=0.013), right ventricular enlargement (OR= 1.98; 95% CI (1.02 3.9); P=0.045), days on effective antibiotics (OR=0.95; 95%CI (0.89 0.99); P=0.04) associated with primary safety outcome. Worsening tricuspid insufficiency and device type were not associated with primary safety outcomes.

Conclusions:
In select patients with RSIE, the majority of whom were refractory to medical therapy alone, PMA demonstrated high rates of procedural success and clinical efficacy. Culture clearance was associated with lower in-hospital mortality. The safety of PMA was acceptable and largely driven by adverse events caused by underlying RSIE.
Comment:
This study suggests that PMA may be a promising treatment method for infective endocarditis in certain patient groups. However, the results should be supported by larger patient groups and prospective studies. In addition, randomized trials are needed to confirm the clinical efficacy and safety of PMA in RSIE.