HJBR Nov/Dec 2022

CARDIAC COMPLICATIONS OF DRUG ABUSE 30 NOV / DEC 2022 I  HEALTHCARE JOURNAL OF BATON ROUGE  or from multiorgan failure secondary to sepsis (a systemic inflammatory reaction to the infec- tion). Additionally, large vegetations may dis- lodge, or embolize, and occlude main vessels and damage vital organs. TREATMENT OF INFECTIVE ENDOCARDITIS Antibiotics remain the mainstay of IE treat- ment. When patients deteriorate, are nonre- sponders to antibiotics, or if there is concern for embolization of the vegetation, mechani- cal solutions are indicated. Until recent years, surgery was the only option for debulking of vegetations. Open heart surgery carries sub- stantial risks and morbidities. Moreover, with IVDUs successfully treated for IE, the disease may recur after repetitive drug use, therefore precluding this population from being treat- ed or subjecting them to redo surgery. Dur- ing open-heart surgery, the damaged valve is often repaired or replaced, and the presence of a foreign body is a predilection for a recur- rent infection. If the infection was not com- pletely cleared, the prosthetic material may get infected. New and less invasive techniques were de- veloped for that reason. Utilizing a percuta- neous approach decreases the operative risk and helps avoid the potential complications of open-heart surgery. With a percutaneous approach, we penetrate a blood vessel for ac- cess through the skin with a needle. We then insert a wire through the needle, remove the needle, and insert a sheath over the wire that has a one-way valve (Seldinger technique). The sheath maintains an open port for inser- tion of the required equipment. AngioVac is an FDA-approved cannula in- dicated for the percutaneous aspiration of masses from heart. The cannula is 0.3 inches in diameter and further expands with a fun- nel-shaped tip once inserted into the body. The cannula is connected by a circuit to a motor, which vacuums blood through a filter and back into the body via an additional ac- cess point. The motor-pump used is usually of a cardio-pulmonary bypass machine or ex- tracorporeal membrane oxygenation (ECMO). The procedure is typically performed under general anesthesia and with the guidance of transesophageal (through the esophagus) echocardiography and fluoroscopy (continu- ous X-ray, such as we use in cardiac catheter- ization laboratory). After we obtain access, the cannula is maneuvered and navigated to the point of interest. We then aspirate the mass. A newer version of the device, called Al- phaVac, is now available. The new device has a manual suction mechanism that eliminates the need for a motor element and a second access point; requires less staff, thus increasing pro- cedure availability; and reduces some of the potential complications. Tulane Medical Center was the first hospital in Louisiana to have used AlphaVac. In the first case, a young woman, 30 years old, was hos- pitalized with IE. She had a large vegetation on the Tricuspid valve and did not respond to antibiotic treatment. Multiorgan failure devel- oped, and she deteriorated to a point of a life- threatening infection. In a discussion between internal medicine, cardio-thoracic surgery, and cardiology, we decided to move forward with percutaneous aspiration of the infec- tious process. The procedure was successfully performed in a fashion specified above. The patient’s condition stabilized, and a few days later, the infection cleared from her blood. After completion of the antibiotic treatment, the patient was discharged from the hospital. Since then, we have used the device in addi- tional cases with a monthly average of use. The procedure enables the antibiotics to pen- etrate the infection, prevents embolization, and does not preclude patients from future cardiac surgery if needed. Moreover, in case of recurrent infection, the procedure can be repeated with no added risk due to the mini- mally invasive approach. FINAL WORDS The best management for drug abuse is prevention, and early treatment is key. How- ever, once complications occur, technologi- cal advancement enable better treatment and save lives. A multidisciplinary approach is vital for better decision making and optimal utiliza- tion of the therapeutic arsenal. Careful atten- tion should be placed when treating an under- served population such as homeless people and drug users since further challenges ac- company in addition to the presenting dis- ease. Despite shortcomings of current treat- ment, more and more tools are added. It is imperative to be familiar with them in order to improve patient management. n ABOUT THE STRUCTURAL HEART PROGRAM IN TULANE MEDICAL CENTER The structural heart clinic in TMC evaluates patients with heart valve problems such as aortic stenosis/regurgitation, mitral stenosis/regurgitation, PFO/ASD for closure, left atrial appendage for closure in patients with stroke, and septal hypertrophy for ablation. In addition, we treat coronary chronic total occlusions, pulmonary embolism, peripheral vascular disease, and aspirate heart masses.