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Infective Endocarditis After TAVR
Study Questions:
What is the incidence, risk factors for, clinical presentation of, and outcomes associated with prosthetic valve endocarditis (PVE) among patients who underwent transcatheter aortic valve replacement (TAVR)?
Methods:
In a retrospective, nationwide follow-up study, a national TAVR registry was used to identify all patients who underwent TAVR in Sweden between January 2008 and September 2019 (n = 4,336 after excluding 206 patients who underwent prior TAVR [undergoing ‘valve-in-valve’ TAVR]). A national diagnosis registry was used to identify cases of infective endocarditis, and an infective endocarditis registry and retrospective chart review were used to supply clinical details for identified patients with TAVR-associated PVE.
Results:
The risk for PVE after TAVR was 1.4% (95% confidence interval [CI], 1.0-1.8%) in the first year, and 0.8% (95% CI, 0.6-1.1%) per year thereafter. One-year survival after PVE diagnosis was 58% (95% CI, 49-68%), and 5-year survival was 29% (95% CI, 17-41%). Body surface area, estimated glomerular filtration rate <30 ml/min/1.73 m2, critical preoperative state, mean preprocedural valve gradient, amount of contrast dye used, transapical access, and atrial fibrillation were identified as independent risk factors for PVE. Staphylococcus aureus was more common in early (<1 year) PVE. Infection with S. aureus, root abscess, late PVE, and noncommunity acquisition was associated with higher 6-month mortality.
Conclusions:
The incidence of PVE after TAVR was similar to historical reports of PVE associated with surgical bioprostheses. Compromised renal function was a strong risk factor for developing PVE. The authors concluded that, in the context of PVE, TAVR seems to be a safe option for patients.
Perspective:
This study found an incidence of PVE after TAVR that was similar to historically reported rates after surgical AVR, concordant with other publications that performed direct comparison (Butt JH, et al., J Am Coll Cardiol 2019;73:1646-55). In another study, hemodialysis was found to be a risk factor for PVE after TAVR (Mangner N, et al., J Am Coll Cardiol 2016;67:2907-8); in this study, compromised renal function was a strong risk factor, but it is not clear whether renal replacement therapy was separately analyzed. The incidence of PVE probably is similar following surgical AVR and TAVR, suggesting that the risk of future infective endocarditis probably is not a reason to choose one therapy or the other. High mortality after TAVR-associated PVE likely is a result of both poor outcomes associated with PVE in general, and the associated age and comorbidities among patients who undergo TAVR.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Atrial Fibrillation, Bioprosthesis, Body Surface Area, Cardiac Surgical Procedures, Endocarditis, Endocarditis, Bacterial, Glomerular Filtration Rate, Heart Valve Diseases, Heart Valve Prosthesis, Renal Dialysis, Renal Replacement Therapy, Risk Factors, Staphylococcus aureus, Transcatheter Aortic Valve Replacement
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