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Prosthetic Valve Endocarditis After TAVR and SAVR
Study Questions:
What are the incidence, risk factors, microbiological profile, and outcomes of prosthetic valve endocarditis (PVE) after transcatheter (TAVR) and surgical aortic valve replacement (SAVR)?
Methods:
A pooled cohort of all patients in PARTNER-I and PARTNER-II trials and registries were analyzed. Patients had severe aortic stenosis, were treated with TAVR or SAVR, and were analyzed with respect to development of PVE; PVE adjudication by a clinical events committee was based on modified Duke Criteria. The incidence, infection timing, organism, and association between PVE and all-cause mortality were analyzed.
Results:
A total of 8,530 patients were included. PVE occurred in 107 cases (5.06 [95% confidence interval (CI), 4.19-6.12] PVE events per 1,000 person-years over a mean follow-up of 2.69 ± 1.55 years). The incidence of TAVR-PVE (5.21 [95% CI, 4.26-6.38] per 1,000 person-years) was not significantly different from SAVR-PVE (4.10 [95% CI, 2.33-7.22] per 1,000 person-years; incidence rate ration [IRR], 1.27 [95% CI, 0.70-2.32]; p = 0.44). Temporal risk of PVE was similar for TAVR and SAVR, even after adjusting for competing risk of death (HR, 1.15 [95% CI, 0.58-2.28; p = 0.69). On multivariable analysis, PVE was associated with baseline cirrhosis (IRR, 2.86 [95% CI, 1.33-6.16; p = 0.007), pulmonary disease (IRR, 1.70 [95% CI, 1.16-2.48; p = 0.006), and renal insufficiency (IRR, 1.71 [95% CI, 1.03-2.83]; p = 0.04). Timing of PVE was similar between TAVR and SAVR (<30 days: 4.2% vs. 8.3%; 31 days-1 year: 52.6% vs. 66.7%; >1 year: 43.2% vs. 25.0%; p = 0.28). Staphylococcus occurred more commonly after SAVR (58.3% vs. 28.4% in TAVR; p = 0.04). PVE was strongly associated with all-cause mortality after endocarditis diagnosis (HR, 4.42 [95% CI, 3.42-5.72; p < 0.0001).
Conclusions:
PVE remains rare, but often fatal, in the modern AVR experience. There is no difference in the incidence, predictors, or risk of PVE between TAVR and SAVR.
Perspective:
PVE is an important albeit relatively uncommon mechanism of prosthetic valve failure after SAVR. As TAVR is used more broadly and in progressively lower-risk patients, it is important to understand if there are substantial differences in the development and course of PVE after TAVR compared to SAVR. This study used the large PARTNER-I and PARTNER-II trials and registries to describe and compare PVE following TAVR and following SAVR, and found no significant differences in the incidence, predictors, or risk of PVE between procedures (TAVR or SAVR) or between different TAVR access or vascular closure methods. Although intermediate-risk patients were included in the registries, future studies will be required to assess the relative risks and outcomes of PVE among lower-risk populations.
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Endocarditis, Heart Valve Diseases, Heart Valve Prosthesis, Liver Cirrhosis, Renal Insufficiency, Risk Factors, Staphylococcus, Transcatheter Aortic Valve Replacement
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