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Surgical Treatment of Patients With Infective Endocarditis After TAVI
Quick Takes
- In this observational, multicenter, international registry analysis, TAVI-IE was associated with a very poor prognosis (in-hospital mortality ~32%, 1-year mortality ~48%).
- Cardiac surgery was less likely to be performed in older patients and those with neurologic symptoms, and more likely to be performed with TAVI platform involvement; vegetation size >10 mm; periannular complications; and complications including heart failure, systemic embolization, or persistent bacteremia.
- Cardiac surgery compared to medical therapy alone for TAVI-IE was not associated with improved hospital mortality or 1-year all-cause mortality.
Study Questions:
What are the clinical characteristics and outcomes of patients with transcatheter aortic valve implantation (TAVI) infective endocarditis (IE) treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB)?
Methods:
The Infectious Endocarditis After TAVI International Registry is an observational, multicenter, international registry with data collected from 604 patients with definite IE after TAVI based on the modified Duke criteria from 59 centers in 11 countries across Europe, North America, and South America between June 2005–November 2020. Using registry data, crude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery versus medical therapy on 1-year all-cause mortality among patients with definite TAVI-IE.
Results:
Among 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Cardiac surgery was less likely to be performed in older patients (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.92-0.98) and those with neurologic symptoms (OR, 0.37; 95% CI, 0.19-0.74); and more likely with TAVI platform involvement (OR, 2.16; 95% CI, 1.36-3.43), vegetation size >10 mm (OR, 2.35; 95% CI, 1.54-3.59), periannular complications (OR, 2.74; 95% CI, 1.73-4.34), and complications including heart failure (OR, 2.14; 95% CI, 1.41-3.25), systemic embolization (OR, 2.67; 95% CI, 1.50-4.77), or persistent bacteremia (OR, 2.27; 95% CI, 1.48-3.49). In-hospital mortality was 31.9%, and 1-year all-cause mortality was 47.9%. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (unadjusted hazard ratio [HR], 0.85; 95% CI, 0.58-1.25) or 1-year all-cause mortality (unadjusted HR, 0.88; 95% CI, 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB also was not associated with lower mortality rates for in-hospital mortality (adjusted HR, 0.92; 95% CI, 0.80-1.05) or 1-year all-cause mortality (adjusted HR, 0.95; 95% CI, 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, infection with Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock.
Conclusions:
In this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patient characteristics, pathogen, and IE-related complications.
Perspective:
The incidence of TAVI-IE (variably estimated at 0.7-3.4%) is similar to the incidence of IE after surgical valve replacement. Small, previously published studies have suggested that cardiac surgery compared to medical therapy alone is not associated with improved in-hospital or 1-year mortality associated with TAVI-IE. This multicenter, international registry-based study revealed poor outcomes associated with TAVI-IE (in-hospital mortality ~32%, 1-year mortality ~48%), with no evident improvement associated with cardiac surgery compared to medical therapy alone. Notably, patients who underwent surgery tended to be different than those who did not, with study limitations and potential bias inherent to any retrospective registry analysis.
Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Anti-Bacterial Agents, Aortic Valve Stenosis, Bacteremia, Cardiac Surgical Procedures, Embolism, Endocarditis, Endocarditis, Bacterial, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Hospital Mortality, Renal Insufficiency, Shock, Septic, Staphylococcus aureus, Transcatheter Aortic Valve Replacement
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