Over recent years, the incidence of right-sided infective endocarditis has increased, driven largely by the rising prevalence of people who inject drugs and by an expanding population of older adults with cardiac implantable electronic devices. These epidemiologic shifts have underscored the need for therapeutic alternatives to conventional surgery, which remains the treatment of choice but may be prohibitively high risk in these patient groups.
The aim of this study was to assess the feasibility, safety, and clinical usefulness of percutaneous mechanical aspiration as a strategy for debulking vegetations in right-sided infective endocarditis, offering a less invasive option compared with conventional surgery.
This multicenter retrospective study included adult patients with right-sided endocarditis treated using percutaneous mechanical aspiration. Patients were enrolled from 19 centers, covering a study period from 2014 through 2024. A total of 256 patients were analyzed.
The CLEAR-IE (Cardiac Lesion Extraction and Aspiration Registry for Infective Endocarditis) is a large, multicenter, retrospective registry of consecutive patients with right-sided infective endocarditis undergoing percutaneous mechanical aspiration. Procedural success was defined as at least a 70% reduction in site-reported vegetation size or a residual diameter ≤1 cm on postprocedural echocardiography. The primary endpoint consisted of in-hospital mortality, new pulmonary embolism, or emergency surgery. Secondary endpoints included each component of the primary endpoint and in-hospital worsening tricuspid regurgitation.
Median age was 43 years; 43% were women, and 51% had a history of injection drug use. Acute pulmonary embolism (50.8%) and cardiogenic shock (27%) were frequent presenting features. Tricuspid valve involvement occurred in 70% of patients, with a median site-reported vegetation size of 2.4 cm. Severe tricuspid regurgitation was present in 31.3% at baseline. Staphylococcus aureus was the dominant pathogen (73.8%). Procedural success reached 89.4%, with a median residual vegetation size of 0.7 cm. Overall, 86.9% of patients completed the procedure free of procedure-related complications. The primary endpoint occurred in 18% (mortality: 9.8%; new pulmonary embolism: 8.3%; emergency surgery: 3.1%). Among patients without baseline severe tricuspid regurgitation, worsening regurgitation was reported in 16.9%. In univariate analysis, shock (OR = 2.27; p = .03) and hypoxia (OR = 3.62; p < .001) were significantly associated with the primary endpoint, whereas worsening tricuspid regurgitation was not. In multivariate analysis, hypoxia (OR = 2.76; p = .006) remained significantly associated with the primary outcome.
The devices used included the AngioVac and AlphaVac systems (AngioDynamics), the FlowTriever system (Inari Medical), and the Lightning system (Penumbra), each offering distinct technical features.
Evidence from the CLEAR-IE registry supports percutaneous mechanical aspiration as a feasible and potentially useful therapeutic option for selected patients with right-sided infective endocarditis, particularly when conventional surgical intervention poses excessive risk. Catheter-based aspiration demonstrated high procedural success, with acceptable rates of adverse events largely attributable to the underlying infectious process. Randomized trials are warranted to further evaluate the clinical effectiveness and safety of percutaneous mechanical aspiration in appropriately selected patients.
COMMENTARY:
Conventional surgery has long been regarded as the sole invasive treatment option for right-sided infective endocarditis. However, evolving epidemiology and shifting patient profiles have led to a substantial rise in the number of right-sided cases. In this study, most patients were young, and slightly more than half were people who inject drugs. Nearly one third carried a cardiac implantable electronic device. Although surgery remains the gold standard, it is not an appropriate option for all patients.
Percutaneous mechanical aspiration has emerged as a supportive—and still controversial—therapeutic alternative owing to limited scientific evidence. In this registry, outcomes were favorable for most patients, achieving the prespecified procedural success threshold. Specifically, procedural success reached 89%, with a median postprocedural vegetation size of 0.7 cm (baseline median 2.4 cm). The primary endpoint occurred in 18% of the cohort. Identified risk factors for the primary outcome included female sex, hypoxia (the strongest predictor), shock, and right ventricular dilation. Negative blood cultures after the procedure were associated with a lower likelihood of reaching the primary endpoint. These findings suggest that despite the high technical success rate, a substantial proportion (18%) still experienced serious in-hospital clinical events—likely driven more by the severity of the underlying disease and patient condition than by the procedure itself.
This study raises important unanswered questions, including which patient subgroups might benefit most from percutaneous mechanical aspiration, given that the registry included only high-risk individuals. Additional considerations include identifying patients in whom this therapy would not be recommended, determining the optimal timing within the disease course, assessing recurrence risk and long-term outcomes, defining inclusion criteria and procedural standardization, and clarifying whether device selection should be uniform—especially since AngioVac was used in most cases. Notably, there were no intraprocedural deaths. Mortality occurred beginning in the first week after the procedure, suggesting that death was primarily related to the underlying infection rather than to aspiration. At 6 weeks, more than 80% of patients were alive.
Several limitations must be acknowledged, including the absence of a comparison group, technical heterogeneity, nonuniform inclusion criteria, and limited information regarding prior antimicrobial therapy. As a result, findings should be interpreted as signals of potential efficacy rather than definitive evidence.
In conclusion, percutaneous mechanical aspiration is a viable therapeutic option for selected complex patients. It expands the range of available treatments beyond surgery or antibiotics alone—an especially relevant consideration for individuals who inject drugs, frail older adults, or those with device-related infections. This study positions percutaneous aspiration not as an experimental maneuver but as a legitimate therapeutic tool whose indication should be individualized through comprehensive evaluation. The results support its consideration within specialized centers and open the door to further exploration, refinement, and comparison with established standard-of-care treatments.
REFERENCE:
El Sabbagh A, Hibbert B, Bangalore S, Fong P, Zlotnick D, El-Sabawi B, et al. Outcomes of percutaneous mechanical aspiration in right-sided infective endocarditis: a multicenter registry. J Am Coll Cardiol. 2025;86(12):846-856. doi: 10.1016/j.jacc.2025.06.054.
