Top Things to Know: Percutaneous Mechanical Aspiration in Patients with Right-Sided Infective Endocarditis
Updated: May 07, 2026
Prepared by Barbara Entl, MD Science and Medicine Advisor American Heart Association
- Percutaneous mechanical aspiration (PMA) is an emerging catheter-based modality for managing right-sided infective endocarditis (RSIE), particularly in patients with inadequate response to antimicrobial therapy or those at high surgical risk.
- While randomized trials are lacking, retrospective studies, multicenter registries, and administrative datasets indicate favorable outcomes in appropriately selected patients. Reflecting this evidence, the 2023 ESC guidelines assign PMA a Class IIb recommendation for high-risk patients with right-sided intra-atrial septic masses.
- Further, a propensity-matched analysis in PWID with tricuspid valve endocarditis showed outcomes comparable to surgery, including similar early mortality and 1-year complication rates, supporting PMA as a potential alternative or staged bridge to valve intervention.
- This science advisory outlines the rationale and evolving role of PMA in RSIE, summarizes available evidence and procedural best practices, offers expert guidance on patient selection, device use, and safety, and highlights remaining knowledge gaps and research priorities.
- Initially developed for pulmonary embolism, PMA uses aspiration catheters to remove thrombotic material and has been adopted off label to debulk large vegetations on endocardial surfaces or cardiac devices. Combined fluoroscopic and echocardiographic guidance enhances precision and procedural safety.
- PMA devices fall into two main categories: continuous-flow and noncontinuous-flow systems. Continuous-flow platforms, such as AngioVac, rely on a veno-venous extracorporeal bypass circuit with two large-bore access sites and filtration, requiring a perfusionist and a more complex setup.
- Noncontinuous-flow systems, including AlphaVac, FlowTriever, and Lightning, avoid extracorporeal circulation by using single-access designs that apply intermittent suction through direct catheter-vegetation contact.
- Growing evidence suggests that earlier surgical intervention may improve outcomes, particularly in patients with persistent bacteremia, vegetations >20 mm, recurrent septic pulmonary emboli, or heart failure from valvular injury.
- Despite its promise, PMA carries procedural risks, including vascular injury, access-site complications, and worsening tricuspid regurgitation, with cardiac perforation reported rarely. Dislodged infectious material may cause distal embolization, including septic pulmonary emboli or paradoxical emboli in patients with a patent foramen ovale or concomitant left-sided disease. Worsening of sepsis can also occur due to vegetation disruption.
- The optimal role of PMA in RSIE remains to be defined. Current data highlight growing interest in the technique but underscore the urgent need for prospective, standardized studies to clarify its safety, efficacy, and place in clinical practice.
Citation
El Sabbagh A, Yucel E, Sethi SS, El-Chami MF, Mattos SS, Estes BA, Zwischenberger BA, Moriarty JM, Andrew SP. Sharp ASP, Baddour LM; on behalf of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Council on Clinical Cardiology. Percutaneous mechanical aspiration in patients with right-sided infective endocarditis: a science advisory from the American Heart Association. J Am Heart Assoc. 2026;15:e050115. doi:10.1161/jaha.126.050115