TAVR and Subsequent Infective Endocarditis
What are the characteristics and outcomes of patients who develop infectious endocarditis following transcatheter aortic valve replacement (TAVR)?
This study examined 20,006 patients from 47 sites treated with TAVR, and compared the characteristics and outcomes of those with subsequent diagnosis of definite infectious endocarditis versus those without.
There were 250 patients with definite infectious endocarditis from the study population (1.1% per person-year, 95% confidence interval [CI], 1.1-1.4%). The median time of endocarditis after TAVR was 5.3 months (interquartile range, 1.5-13.4 months). Variables associated with increased risk of infectious endocarditis included younger age (78.9 vs. 81.8 years; hazard ratio [HR], 0.97 per year; 95% CI, 0.94-0.99), male gender (62.0 vs. 49.7%; HR, 1.69; 95% CI, 1.13-2.52), diabetes mellitus (41.7 vs. 30.0%; HR, 1.52; 95% CI, 1.02-2.29), and ≥ moderate residual aortic regurgitation (22.4 vs. 14.7%; HR, 2.05; 95% CI, 1.28-3.28). Performance of the TAVR procedure in an operating room versus catheterization laboratory (p = 0.47), or the use of a self-expanding versus balloon-expandable valve (p = 0.34) was not associated with a difference in the incidence of endocarditis. The source of endocarditis was intravascular or soft tissue infection in 10.4%, while the source in 69.6% of cases was unknown. Health care-associated endocarditis was seen in 52.8% of cases. The most common causative organisms were enterococci (24.6%), staphylococcus aureus (23.3%), and coagulase-negative staphylococci (16.8%). The in-hospital mortality rate was 36% in patients with endocarditis, with a 2-year mortality rate of 66.7%.
Risk factors for endocarditis include younger age, male gender, diabetes mellitus, and at least moderate residual aortic regurgitation. These patients have high rates of mortality.
These data help define the typical incidence, risk factors, characteristics, and outcomes of infectious endocarditis after TAVR. The rate of endocarditis after TAVR appears comparable to that of surgical valve replacement, and was not different between groups treated with self-expanding versus balloon-expandable valves, or between patients with procedures in operating rooms versus catheterization laboratories. The only modifiable risk factor for infectious endocarditis was the presence of at least moderate residual aortic regurgitation, which emphasizes the need for continued improvements in valve design and delivery to reduce aortic regurgitation following TAVR.
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