Abstract 4360296: Beyond Antibiotics: Transcatheter AngioVac Debulking of Right-Sided Methicillin-Resistant Staphylococcus aureus Endocarditis in a Hemodialysis Patient

Abstract

Background: Methicillin-Resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is a serious complication in hemodialysis patients with indwelling catheters, with mortality rates up to 30 to 40%. Right-sided IE, although less common, presents diagnostic challenges, especially when vegetations are localized to central venous structures. In catheter-associated infections, vegetations may lie in areas poorly visualized by transthoracic echocardiography. Surgical intervention carries high perioperative risk in patients with ESRD and sepsis. In select cases, transcatheter debulking with the AngioVac system may offer a minimally invasive, life-saving alternative. Case Presentation: A 51-year-old female with ESRD on hemodialysis via a right tunneled catheter presented with fever and left knee pain. She was febrile and septic on admission; blood cultures grew MRSA. IV vancomycin was started, and the catheter was removed. Initial transthoracic echocardiography (TTE) showed no vegetations or intracardiac masses. CT chest post catheter removal revealed vegetations on the tricuspid valve, in the SVC, and right brachiocephalic vein with septic pulmonary emboli. Transesophageal echocardiography (TEE) showed a large, mobile, multilobular vegetation on the anterior tricuspid leaflet extending into the right atrium and SVC, with severe tricuspid regurgitation. She underwent transcatheter debulking with AngioVac, successfully removing vegetations from the tricuspid valve, SVC, brachiocephalic vein, and right heart. No residual vegetations were seen post-procedure. MRSA was also isolated from the left knee aspirate; she underwent incision and drainage. Blood cultures cleared following catheter removal and AngioVac intervention. She was discharged to a skilled nursing facility for rehabilitation and completed a six-week course of IV vancomycin. Discussion: This case highlights the importance of early recognition and multidisciplinary management of catheter-associated MRSA IE. Vegetations may be missed on initial imaging when located in central venous structures. Catheter removal can unmask or dislodge vegetations, leading to septic emboli. Persistent bacteremia after catheter removal should raise suspicion for significant residual vegetations in the SVC or right heart chambers. In this high-risk patient, AngioVac enabled effective source control without surgery. This case highlights AngioVac as a valuable tool in managing right-sided IE in nonsurgical candidates.