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Incidence, Predictors, and Outcomes of Endocarditis After TAVR
Quick Takes
- The incidence of infective endocarditis (IE) after TAVR is low (0.87% per year).
- Factors associated with IE after TAVR include younger age; male sex; prior IE; repeat procedures; and liver, lung, and kidney disease.
- Thirty-day and 1-year mortality associated with IE after TAVR were 18.5% and 45.6%, respectively.
Study Questions:
What are the incidence and outcomes of infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR)?
Methods:
The study investigated Medicare patients who underwent TAVR from 2012 through 2017, and identified patients admitted with IE during follow-up using International Classification of Diseases (ICD)-9 and ICD-10 codes and a validated algorithm. The main study outcome was all-cause mortality.
Results:
Of 134,717 patients who underwent TAVR, 1,868 patients (1.39%) developed IE during follow-up (incidence 0.87%/year [respectively 0.57% and 0.30%/year for early and for late IE]), with the majority of infections (65.0%) occurring within 1 year. The incidence of endocarditis declined in recent years. The most common organisms were Staphylococcus (22.0%), Streptococcus (20.0%), and Enterococcus (15.5%). Important predictors for IE were younger age at TAVR, male sex, prior IE, end-stage renal disease, repeat TAVR procedures, liver and lung disease, and post-TAVR acute kidney injury. Thirty-day and 1-year mortality were 18.5% and 45.6%, respectively. After adjusting for comorbidities and procedural complications, IE after TAVR was associated with threefold higher risk of mortality (44.9 vs. 16.2 deaths per 100 person-years, adjusted hazard ratio [HR], 2.94; 95% confidence interval [CI], 2.77-3.12; p < 0.0001). Higher mortality following IE (p < 0.05 for all) was associated with end-stage renal disease (HR, 2.12; 95% CI, 1.72-2.60), IE complicated by cardiogenic shock (HR, 2.50; 95% CI, 1.56-4.02), ischemic stroke (HR, 1.56; 95% CI, 1.07-2.28), intracerebral hemorrhage (HR, 1.67; 95% CI, 1.01-2.76), acute kidney injury (HR, 1.44; 95% CI, 1.27-1.63), blood transfusion (HR, 1.28; 95% CI, 1.09-1.50), staphylococcal (HR, 1.71; 95% CI, 1.49-1.97) and fungal IE (HR, 1.72; 95% CI, 1.23-2.39).
Conclusions:
The incidence of endocarditis after TAVR is low and declining, but associated with poor prognosis, with one-half of patients dying within 1 year.
Perspective:
Previously published reports of IE after TAVR were based on relatively small sample sizes. This large study that included only Medicare patients utilized an administrative database, with all of its inherent limitations—including the reliance on ICD codes for the diagnosis of IE and for microbiological diagnoses, and an absence of data regarding imaging (to identify the site of infection and associated complications) and antibiotic therapy. In addition to providing risk factors for developing IE after TAVR and for adverse outcomes associated with IE after TAVR, this study reinforces the devastating clinical outcomes associated with prosthetic valve IE.
Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Acute Kidney Injury, Brain Ischemia, Cardiac Surgical Procedures, Endocarditis, Enterococcus, Heart Valve Diseases, Hemorrhage, Liver Diseases, Lung Diseases, Risk Factors, Renal Insufficiency, Shock, Cardiogenic, Staphylococcus, Streptococcus, Stroke, Transcatheter Aortic Valve Replacement
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