Endocarditis in TAVR | Journal Scan
What are the incidence, predictors, and outcomes of infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR)?
This registry examined 7,944 patients treated with TAVR at 21 sites between 2007 and 2014, and compared the patients who developed IE to those who did not.
Mean age was 79 ± 8 years and 57% were men. All centers used prophylactic antibiotics during the procedure. Mean follow-up was 1.1 ± 1.2 years, with a median time from TAVR to IE of 6 months (interquartile range, 1-14 months). IE was observed in 0.67% of patients (n = 53) overall, and 0.50% at 1 year. All patients were treated with prolonged antibiotic regimens. The most common associated organisms were coagulase-negative staphylococci, Staphylococcus aureus, and enterococci (24%, 21%, and 21%, respectively). In the 3,067 patients with complete data, variables independently associated with IE were orotracheal intubation (hazard ratio [HR], 3.9; 95% confidence interval [CI], 1.6-9.6; p = 0.004) and the use of a self-expandable device (HR, 3.1; 95% CI, 1.4-7.1; p = 0.007). Exposure to a procedure that could cause bacteremia (e.g., urological, gastrointestinal, and odonatological procedures) was observed in 27 (51%) of these patients. Repeat valve intervention was performed in 11% of patients (n = 6), and complications of IE were observed in 87% of individuals. Mortality during hospitalization and at 1 year was 47% and 66%, respectively.
IE was observed in 0.7% of patients following TAVR. These patients rarely underwent repeat valve procedures, and experienced high rates of mortality.
This study observed IE in 0.7% of patients following TAVR, which is comparable to rates previously reported for surgical aortic valve replacement (SAVR). Despite the less invasive nature of TAVR, these patients typically have more comorbidities, which may explain the similar rate of IE. The observation that over one half of patients with IE were exposed to procedures that may cause bacteremia raises important issues regarding the use of antibiotic prophylaxis, and should prompt further study to determine whether current guidelines for antibiotic prophylaxis are adequate. It is also notable that enterococci were a frequent pathogen, as this can be introduced with groin access for the TAVR procedure. The study also reports a higher rate of IE with a self-expanding device. The reason for this is unclear, but one possibility is limited site experience, as 80% of procedures in this study were performed using a balloon-expandable device, and less site experience has been associated with increased rates of complications. It is also possible that there are some intrinsic differences in the device itself or the deployment procedure that alter the risk of IE, and this merits additional study. Finally, very few patients underwent repeat valve intervention, which may have been due to the frequent comorbidities in this population. These individuals had a very poor prognosis, and these results should prompt careful discussion of the management options in these patients.
Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Transcatheter Aortic Valve Replacement, Anti-Bacterial Agents, Antibiotic Prophylaxis, Aortic Valve, Bacteremia, Coagulase, Comorbidity, Endocarditis, Endocarditis, Bacterial, Enterococcus, Heart Valve Prosthesis, Incidence, Intubation, Hospital Mortality, Prognosis, Staphylococcus aureus, Heart Valve Diseases, Cardiac Surgical Procedures, Registries
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