Incidence, Predictors, and Outcomes of Endocarditis After Transcatheter Aortic Valve Replacement in the United States

The Promise and Perils of Transcatheter Aortic Valve Replacement (TAVR) in Low Surgical Risk Patients with Severe Aortic Stenosis in the Current Era

PURPOSE OF REVIEW

Transcatheter Aortic Valve Replacement (TAVR) has become the preferred treatment approach for many patients with symptomatic severe aortic valve stenosis (SsAS), particularly those who are deemed at high surgical risk. However, in low-risk surgical patients (LSRP) with SsAS, the choice between TAVR and surgical aortic valve replacement (SAVR) is often a matter of debate and depends on several clinical and anatomical considerations.

RECENT FINDINGS

Midterm data show similar clinical outcomes and durability of TAVR and SAVR bioprosthetic valves in LRSP. Data on long term durability and outcomes of TAVR in LRSP remains scarce. Both TAVR and SAVR are reasonable options in LRSP with SsAS. Nevertheless, many of these LRSP are expected to outlive their bioprosthetic valves and planning for the second aortic valve replacement should begin at the time of the index procedure with special consideration for coronary re-access, risk for coronary obstruction, and prothesis patient mismatch.

Comparison of Patient Outcomes Between Leadless vs Transvenous Pacemakers Following Transcatheter Aortic Valve Replacement

BACKGROUND

Evidence is limited regarding the effectiveness of leadless pacemaker implantation for conduction disturbance following transcatheter aortic valve replacement (TAVR).

OBJECTIVES

This study sought to examine the national trends in the use of leadless pacemaker implantation following TAVR and compare its performance with transvenous pacemakers.

METHODS

Medicare fee-for-service beneficiaries aged ≥65 years who underwent leadless or transvenous pacemakers following TAVR between 2017 and 2020 were included. Outcomes included in-hospital overall complications as well as midterm (up to 2 years) all-cause death, heart failure hospitalization, infective endocarditis, and device-related complications. Propensity score overlap weighting analysis was used.

RESULTS

A total of 10,338 patients (730 leadless vs 9,608 transvenous) were included. Between 2017 and 2020, there was a 3.5-fold increase in the proportion of leadless pacemakers implanted following TAVR. Leadless pacemaker recipients had more comorbidities, including atrial fibrillation and end-stage renal disease. After adjusting for potential confounders, patients with leadless pacemakers experienced a lower rate of in-hospital overall complications compared with patients who received transvenous pacemakers (7.2% vs 10.1%; P = 0.014). In the midterm, we found no significant differences in all-cause death (adjusted HR: 1.13; 95% CI: 0.96-1.32; P = 0.15), heart failure hospitalization (subdistribution HR: 0.89; 95% CI: 0.74-1.08; P = 0.24), or infective endocarditis (subdistribution HR: 0.98; 95% CI: 0.44-2.17; P = 0.95) between the 2 groups, but leadless pacemakers were associated with a lower risk of device-related complications (subdistribution HR: 0.37; 95% CI: 0.21-0.64; P < 0.001).

CONCLUSIONS

Leadless pacemakers are increasingly being used for conduction disturbance following TAVR and were associated with a lower rate of in-hospital complications and midterm device-related complications compared to transvenous pacemakers without a difference in midterm mortality.

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Infection of Transcatheter Valvular Devices

PURPOSE OF REVIEW

This review explores the epidemiology, clinical traits, and diagnosis of Transcatheter Aortic Valve Replacement-Associated Infective Endocarditis (TAVR-IE) and mitral transcatheter edge-to-edge repair infective endocarditis (TEER-IE), focusing on a multimodal imaging approach. It addresses the rising prevalence of TAVR and TEER, emphasizing the need to understand long-term complications and clinical consequences, which poses significant challenges despite advancements in valve technology.

RECENT FINDINGS

Studies report a variable incidence of TAVR-IE and TEER-IE influenced by diverse patient risk profiles and procedural factors. Younger age, male gender, and certain comorbidities emerge as patient-related risk factors. Procedure-related factors include intervention location, valve type, and technical aspects. Microbiologically, Staphylococcus aureus, Viridans Group Streptococcus, and Enterococcus are frequently encountered pathogens. TAVR-IE and TEER-IE diagnosis involves a multimodal imaging approach due to limitations in echocardiography. Blood cultures and imaging aid identification, with Fluorescence in situ hybridization is showing promise. Treatment encompasses medical management with antibiotics and, when necessary, surgical intervention. The management approach requires a multidisciplinary "Endocarditis Team." This review underscores the need for continued research to refine risk prediction, enhance diagnostic accuracy, and optimize management strategies for TAVR-IE, considering the evolving landscape of transcatheter interventions.

Ten-Year Experience with a Transapical Approach for Transcatheter Aortic and Mitral Valve Implantation

BACKGROUND

The transfemoral approach represents the optimal access for TAVI due to its low invasiveness; however, up to 10-15% of TAVI candidates are considered unsuitable for femoral access because of significant peripheral vascular disease and need alternative access.

METHODS

This is a single-center retrospective observational study including all consecutive adult patients undergoing transcatheter procedures through a TA approach from March 2015 to April 2024.

RESULTS

213 patients underwent transcatheter aortic or mitral valve implantation through a TA approach and were enrolled in this study. The mean age of the patients was 79.5 ± 5.7 years, and 54% of the patients were males. The mean Euroscore II was 7.9 ± 6.4%. One-third of the patients had previous cardiac surgery. The overall mean survival time was 5.3 ± 0.3 years. Nine (4%) patients developed infective endocarditis (IE) during the follow-up.

CONCLUSIONS

The transapical approach for transcatheter procedures is a safe and effective procedure for patients unsuitable for TF access with low periprocedural mortality and a low rate of post-procedural complications when performed by experienced surgeons and cardiologists.

Aortic Stenosis Management in Patients With Acute Hip Fracture

The treatment of severe aortic stenosis (SAS) has evolved rapidly with the advent of minimally invasive structural heart interventions. Transcatheter aortic valve replacement has allowed patients to undergo definitive SAS treatment achieving faster recovery rates compared to valve surgery. Not infrequently, patients are admitted/diagnosed with SAS after a fall associated with a hip fracture (HFx). While urgent orthopedic surgery is key to reduce disability and mortality, untreated SAS increases the perioperative risk and precludes physical recovery. There is no consensus on what the best strategy is either hip correction under hemodynamic monitoring followed by valve replacement or preoperative balloon aortic valvuloplasty to allow HFx surgery followed by valve replacement. However, preoperative minimalist transcatheter aortic valve replacement may represent an attractive strategy for selected patients. We provide a management pathway that emphasizes an early multidisciplinary approach to optimize time for hip surgery to improve orthopedic and cardiovascular outcomes in patients presenting with HFx-SAS.

Perioperative renal function change after transcatheter aortic valve replacement: A single-center retrospective study in China

BACKGROUND

In recent years, the kidney function after Transcatheter Aortic Valve Replacement (TAVR) has gradually become a hot spot that arouse extensive attention.Our study is aimed to evaluate the incidence and predictors of acute kidney recovery (AKR) after TAVR.

METHODS

A total of 102 patients undergoing TAVR in Beijing Anzhen Hospital from June 2021 to March 2022 were enrolled in our study. Patients were divided into AKR group (n = 54), unchanged group (n = 40) and acute kidney injury (AKI) group (n = 8) based on the percent change of estimated glomerular filtration rate (eGFR). Univariate analysis was used to compare the differences in general clinical characteristics and other related indicators between the three groups to analyze the risk factors of AKR.

RESULTS

The incidence of AKR was 53% (54/102) after TAVR. Multivariate analysis showed that the incidence of age and proportion of severe NYHA class (III or IV) was significantly higher in the AKR group while renal dysfunction (eGFR <60 mL/min/1.73 m2) was lower. Besides, fluid management/volume therapy was significantly different among the three groups.

CONCLUSIONS

AKR is a generalizable phenomenon occurring frequently after TAVR. The age, proportion of severe NYHA class and the baseline renal function are independent predictors of AKR events in patients with severe aortic stenosis undergoing TAVR.

The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4

During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.

Impact of mandatory preoperative dental screening on post-procedural risk of infective endocarditis in patients undergoing transcatheter aortic valve implantation: a nationwide retrospective observational study

Background

Guidelines recommend preoperative dental screening (PDS) prior to cardiac valve surgery, to reduce the incidence of prosthetic valve infective endocarditis (IE). However, limited data support these recommendations, particular in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the effect of mandatory PDS on risk of IE in patients undergoing TAVI.

Methods

In this observational study, a total of 1133 patients undergoing TAVI in Western-Denmark from 2020 to 2022 were included. Patients were categorized based on two implemented PDS practices: mandatory PDS (MPDS group), and no referral for PDS (NPDS group). Outcome data were retrieved from Danish registries and confirmed using medical records. The primary outcome was incidence of IE. Secondary outcomes were all-cause mortality and composite outcome of all-cause mortality and IE.

Findings

Of 568 patients in the MPDS group 126 (22.2%) underwent subsequent oral dental surgery, compared to 8 (1.4%) among 565 patients in the NPDS group. During a median follow-up of 1.9 years (interquartile range 1.4-2.5 years), 31 (2.7%) developed IE. The yearly incidence IE rate was 1.4% (0.8-2.3) and 1.5% (0.8-2.4) in MPDS and NPDS, respectively, p = 0.86. All-cause mortality rates were similar between groups (estimated 2-year overall mortality of 6.7% (4.8-9.2) vs. 4.7% (3.2-6.9), MPDS and NPDS, respectively, p = 0.15). Consistent findings were found in 712 propensity score-matched patients.

Interpretation

Mandatory PDS did not demonstrate reduced risk of IE or all-cause mortality compared to targeted PDS in patients undergoing TAVI.

Funding

The funder had no role in the study design, data management, or writing.

Patient Characteristics, Microbiology, and Mortality of Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is associated with high mortality and surgery is rarely performed. Thus, to inform on preventive measures and treatment strategies, we investigated patient characteristics and microbiology of IE after TAVI.

METHODS

Using Danish nationwide registries, we identified patients with IE after TAVI, IE after non-TAVI prosthetic valve (nTPV), and native valve IE. Patient characteristics; overall, early (≤12 m), and late IE (>12 m) microbiology; and unadjusted and adjusted mortality were compared.

RESULTS

We identified 273, 1022, and 5376 cases of IE after TAVI, IE after nTPV, and native valve IE. Age and frailty were highest among TAVI IE (4.8%; median age: 82 y; 61.9% frail). Enterococcus spp. were common for IE after TAVI (27.1%) and IE after nTPV (21.2%) compared with native valve IE (11.4%). Blood culture-negative IE was rare in IE after TAVI (5.5%) compared with IE after nTPV (15.2%) and native valve IE (13.5%). The unadjusted 90-day mortality was comparable, but the 5-year mortality was highest for IE after TAVI (75.2% vs 57.2% vs 53.6%). In Cox models adjusted for patient characteristics and bacterial etiology for 1-90 days and 91-365 days, there was no significant difference in mortality rates.

CONCLUSIONS

Patients with IE after TAVI are older and frailer, enterococci and streptococci are often the etiologic agents, and are rarely blood culture negative compared with other IE patients. Future studies regarding antibiotic prophylaxis strategies covering enterococci should be considered in this setting.

Endocarditis after Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) use is gaining momentum as the mainstay for the treatment of aortic stenosis compared to surgical aortic valve replacement (SAVR). Unfortunately, TAVR-related infective endocarditis (TAVR-IE) is expected to be detected more and more as a result of the ever-expanding indications in younger patients. Given the overall poor prognosis of TAVR-IE, it is imperative that clinicians familiarize themselves with common presentations, major risk factors, diagnostic pitfalls, therapeutic approaches, and the prevention of TAVR-IE. Herein, we review all of the above in detail with the most updated available literature.

Infective Endocarditis Following Aortic Valve Replacement: A Systematic Review

Aortic valve replacement (AVR) successfully treats aortic valve stenosis and aortic regurgitation from aging or bicuspid aortic valves. The procedure intends to restore the obstructed left ventricular outflow tract (LVOT). AVR can be performed surgically (surgical aortic valve replacement (SAVR); open heart) or via transcatheter (transcatheter aortic valve replacement (TAVR)), typically done through a femoral approach as a minimally invasive procedure, allowing for quicker recovery and reduced hospital stays. AVR has many complications, including life-threatening ones, such as infective endocarditis (IE), retarding the recovery process and increasing mortality following surgery. IE is an uncommon and deadly condition that involves multiple organ systems and is caused by bacteremia stemming from a microorganism that enters the bloodstream. Many manifestations are involved in the development of IE, such as fevers, flu-like symptoms, splinter hemorrhages, Osler nodes, abscesses, and vegetations found on the valves at the leaflets. Vegetations and abscesses tend to create further complications, such as stroke and acute kidney injury, as emboli block blood flow, leading to ischemia and damage. This paper aims to evaluate the difference in SAVR- and TAVR-associated IE, as the goal is to elucidate a danger that diminishes the positive effects of either procedure despite its rarity. Studies have been inconclusive in determining whether or not there is a trend, let alone a difference in incident rates. Both procedures share similar risk factors, but SAVR-associated IE is usually caused by Staphylococcus aureus, and studies indicate possibly Enterococcus spp. in TAVR-associated IE. Incident rates of IE are much higher than they should be, whether or not they differ between procedures, and future research needs to consider the pathways and risk factors that can be used to reduce the occurrence of AVR-associated IE.

Long-Term Prognosis and Predictors of Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: A Retrospective Analysis

BACKGROUND

Aortic valve disease is a common and impactful disorder that imposes significant health burdens and is associated with increased mortality rates. Particularly noteworthy is the emergence of transcatheter aortic valve replacement (TAVR), a minimally invasive procedure that has revolutionized the management of aortic valve disease. However, there remain certain unresolved questions and ongoing research regarding the long-term effectiveness and suitability of TAVR in various patient populations, underscoring the need for further investigation and clinical scrutiny.

OBJECTIVE

This retrospective analysis aimed to investigate the long-term outcomes and predictors of mortality in 500 patients who underwent transcatheter aortic valve replacement (TAVR).

METHODS

This retrospective analysis included individuals who received transcatheter aortic valve replacement (TAVR) at Sri Venkata Sai (SVS) Medical College, Mahabubnagar, Telangana, India, between January 2020 and July 2023. Demographic characteristics, including age, gender, and comorbidities, were recorded, and long-term outcomes after TAVR were assessed, including the incidence of survival rates and major adverse cardiac events (MACE). Predictors of mortality were also identified using Cox proportional hazards regression analysis.

RESULTS

The study group exhibited an average age of 75.6 years (standard deviation (SD): 6.8), with 58% male and 42% female patients. Hypertension (74%), coronary artery disease (CAD) (68%), diabetes mellitus (DM) (42%), and chronic kidney disease (CKD) stage ≥ 3 (36%) were prevalent comorbidities. The median follow-up duration was 5.2 years (interquartile range (IQR): 4.3-6.8 years). The overall long-term survival rate after TAVR was 73.5% (95% confidence interval (CI): 69.8%-77.1%). Additionally, MACE occurred in 21% of patients throughout the follow-up period. The cumulative incidence of MACE at one year, three years, and five years was 6.8% (95% CI: 4.2%-9.5%), 14.2% (95% CI: 10.6%-18.7%), and 21.8% (95% CI: 17.3%-26.7%), respectively. The study found that higher age (hazard ratio (HR): 1.08, 95% CI: 1.04-1.12, p < 0.001), male gender (HR: 1.48, 95% CI: 1.15-1.91, p = 0.002), and the presence of CAD (HR: 1.72, 95% CI: 1.29-2.30, p < 0.001) were linked to an elevated risk of mortality. Additionally, diabetes mellitus (HR: 1.39, 95% CI: 1.05-1.85, p = 0.022) and CKD stage ≥ 3 (HR: 1.96, 95% CI: 1.47-2.61, p < 0.001) emerged as notable predictors of mortality. Conversely, a history of prior coronary artery bypass grafting (CABG) (HR: 0.62, 95% CI: 0.46-0.84, p = 0.003) was associated with a reduced risk of mortality. No significant associations were found between mortality and hypertension (HR: 1.12, 95% CI: 0.88-1.43, p = 0.360) or prior percutaneous coronary intervention (PCI) (HR: 1.21, 95% CI: 0.88-1.67, p = 0.245).

CONCLUSION

Age, male gender, CAD, DM, and CKD stage ≥ 3 were significant indicators of mortality risk in TAVR patients. Risk stratification and individualized management are crucial in optimizing long-term outcomes following TAVR procedures.

Commensal Streptococcal Infective Endocarditis of the Native Mitral Valve in a Transcatheter Aortic Valve Replacement (TAVR) Patient: A Heartful, a Handful, and a Mouthful

An 88-year-old woman with an extensive medical history presented to the hospital with altered mental status, vague abdominal pain, and dysuria. A previous transcatheter aortic valve replacement (TAVR) prosthesis was known to be failing and was suspected to have acquired a vegetation. No other infective endocarditis (IE) stigmata were present. Fortunately, the work-up for replacement was allowed to proceed with a broader cardiac examination from which a mitral vegetation was identified and IE then treated.

Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions

Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.

Infective Endocarditis After Transcatheter Aortic Valve Implantation: A Systematic Review

Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is a rare but potentially fatal event. In this systematic review, we searched PubMed and Embase for large TAVI studies and registries to identify the incidence, presentation, microbiology, risk factors, and outcomes of IE in this population. After application of the selection criteria and quality assessment, 8 studies representing 255,310 TAVR cases and 4218 cases of IE qualified for this review. IE following TAVI is uncommon with an incidence of 0.87 to 1.7 events per 100 person-years. Most events occur in the first year following valve implantation. Staphylococcus , Enterococcus , and Streptococcus species are the most common pathogens. Risk factors include age, sex, concomitant comorbidities, and procedural factors. Outcomes are dismal, and surgical intervention is rare in this population.

Infective Endocarditis after Transcatheter Aortic Valve Replacement: Challenges in the Diagnosis and Management

Although initially conceived for high-risk patients who are ineligible for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is now recommended in a wider spectrum of indications, including among young patients. However, similar to SAVR, TAVR is also associated with a risk of infectious complications, namely, prosthetic valve endocarditis (PVE). As the number of performed TAVR procedures increases, and despite the low incidence of PVE post-TAVR, clinicians should be familiar with its associated risk factors and clinical presentation. Whereas the diagnosis of native valve endocarditis can be achieved straightforwardly by applying the modified Duke criteria, the diagnosis of PVE is more challenging given its atypical symptoms, the lower sensitivity of the criteria involved, and the low diagnostic yield of conventional echocardiography. Delay in proper management can be associated with increased morbidity and mortality. Therefore, clinicians should have a high index of suspicion and initiate proper work-up according to the severity of the illness, the underlying host, and the local epidemiology of the causative organisms. The most common causative pathogens are Gram-positive bacteria such as Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., and Streptococcus spp. (particularly the viridans group), while less-likely causative pathogens include Gram-negative and fungal pathogens. The high prevalence of antimicrobial resistance complicates the choice of therapy. There remain controversies regarding the optimal management strategies including indications for surgical interventions. Surgical assessment is recommended early in the course of illness and surgical intervention should be considered in selected patients. As in other PVE, the duration of therapy depends on the isolated pathogen, the host, and the clinical response. Since TAVR is a relatively new procedure, the outcome of TAVR-PVE is yet to be fully understood.

Infective Endocarditis After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review

Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR procedure (less invasive) and its expansion to younger and healthier patients, the incidence of IE after TAVR remains stable, with incidence rates similar to those reported after surgical aortic valve replacement. Although IE after TAVR is recognized as a subtype of prosthetic valve endocarditis, this condition represents a particularly challenging scenario given its unique clinical and microbiological profile, the high incidence of IE-related complications, the uncertain role of cardiac surgery, and the dismal prognosis in most patients with TAVR-IE. The number of TAVR procedures is expected to grow exponentially in the coming years, increasing the number of patients at risk of developing this life-threatening complication. Therefore, a detailed understanding of this disease and its complications will be essential to improve clinical outcomes.

Risk of Infective Endocarditis Associated with Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: A Propensity Score-Based Analysis

Background: Infective endocarditis (IE) is a feared complication after surgical aortic valve replacement (SAVR)/transcatheter aortic valve implantation (TAVI). It is not certain which procedure carries a higher risk. Our aim was to assess the risk of IE after SAVR/TAVI. Methods: We conducted an observational study of a prospective cohort, including patients with TAVI/SAVR, from March 2015 to December 2020. IE was defined according to the modified Duke’s criteria. IE occurring during the first 12 months of the procedure was considered early IE, and an episode occurring after 12 months was considered late IE. The propensity score was designed to include variables previously associated with TAVI/SAVR and IE. An inverse probability of treatment weight was generated. Results: In total, 355 SAVR and 278 TAVI were included. Median follow-up, 38 vs. 41 months, p = 0.550. IE occurred in 5 SAVR (1.41%, 95% CI 0.2−2.6) vs. 13 TAVI (4.65%, 95% CI 2.2−7.2), p = 0.016. TAVI patients had more frequent early IE (3.2% vs. 0.3%, p = 0.006). In the PS analyses, IE risk did not differ: OR 0.65, 95% CI 0.32−1.32. Factors associated with TAVI IE included younger age (74y vs. 83y, p = 0.030), complicated diabetes mellitus (38.5% vs. 6.8%, p = 0.002), COPD (46.2% vs. 16.3%, p = 0.015), advanced heart failure (100% vs. 52.9%, p < 0.001), and peripheral arteriopathy (61.5% vs. 26.7%, p = 0.011). Conclusions: Early IE was higher with TAVI, but in the PS analyses, the risk attributable to each procedure was similar. Studies are needed to identify and optimize the risk factors of IE prior to TAVI.

Early versus late discharge after transcatheter aortic valve replacement and readmissions for permanent pacemaker implantation

OBJECTIVE

To examine the rate of readmission for permanent pacemaker (PPM) implantation with early versus late discharge after transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a current trend toward early discharge after TAVR. However, paucity of data exists on the impact of such practice on readmissions for PPM implantation.

METHODS

The Nationwide Readmission Database 2016-2018 was queried for all hospitalizations where patients underwent TAVR. Hospitalizations were stratified into early (Days 0 and 1) versus late (≥Day 2) discharge groups. Observations in which PPM was required in the index admission were excluded. Multivariable regression analyses involving patient- and hospital-related variables were utilized. The primary outcome was 90-day readmission for PPM implantation.

RESULTS

The final analysis included 68,482 TAVR hospitalizations, 20,261 (29.6%) with early versus 48,221 (70.4%) with late discharge. Early discharge after TAVR increased over the study period (16.2% in 2016 vs. 37.9% in 2018, P_trend  < 0.01). Nevertheless, 90-day readmission for PPM implantation remained stable (1.8% in 2016 vs. 2.0% in 2018, P_trend  = 0.32). The 90-day readmission rate for PPM implantation (2.0% vs. 1.8%; adjusted odds ratio: 1.15; 95% confidence interval: 0.95-1.39; p = 0.15) and median time-to-readmission (5 days [interquartile range, IQR 3-9] vs. 5 days [IQR 3-14], p = 0.92) were similar with early versus late discharge. Similar rates were observed regardless of whether readmission was elective versus not. Early discharge was associated with lower hospitalization cost ($39,990 ± $13,681 vs. $46,750 ± $18,218, p < 0.01) compared with late discharge.

CONCLUSION

In patients who did not require PPM during the index TAVR hospitalization, the rate of readmission for PPM implantation was similar with early versus late discharge.

Transcatheter Aortic Valve Replacement-Associated Infective Endocarditis: Comparison of Early, Intermediate, and Late-Onset Cases

Background

Transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) is a relatively rare complication of TAVR. Little is known about the characteristics of early, intermediate, and late-onset TAVR-IE.

Methods

We studied the risk factors, microbiological patterns, and diagnostic and treatment strategies in patients with early (<60 days), intermediate (60-365 days), and late-onset (>1 year) TAVR-IE.

Results

Ten out of 494 definite cases of prosthetic valve IE between 2007 and 2019 were confirmed to have TAVR-IE from the IE registry at our center. The mean age was 78.1 ± 13.7 years, with 50% being female. The mean Society of Thoracic Surgeons risk score was 7.8 ± 5.7. Most (60%) TAVR-IE cases had an intermediate onset, with Staphylococcus aureus being the most common organism (66.6%). 18-fluorodeoxyglucose positron emission tomography aided in diagnosis of TAVR-IE in 20% of cases. Mortality due to IE was observed in 40% of cases. Most of the patients underwent conservative management, and 37.5% survived over a mean follow-up of 709 ± 453 days. Two patients underwent surgery, of whom one died on day 30 postoperatively from sepsis. Mortality due to IE occurred in 25% of cases in the early and intermediate-onset groups, while there was 100% mortality in the late-onset group.

Conclusions

In a single-center cohort, most TAVR-IE cases had an intermediate onset, with Staphylococcus aureus being the most common organism. Understanding timing of TAVR-IE may have important prognostic implications.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

Risk of infective endocarditis after surgical and transcatheter aortic valve replacement

Objective

To define the incidence and risk factors for infective endocarditis (IE) following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).

Methods

All patients who underwent first SAVR or TAVI in England between 2007 and 2016 were identified from the NICOR databases. Hospital admissions with a primary diagnosis of IE were identified by linkage with the NHS Hospital Episode Statistics database. Approval was obtained from the NHS Research Ethics Committee.

Results

2057 of 91 962 patients undergoing SAVR developed IE over a median follow-up of 53.9 months—an overall incidence of 4.81 [95% CI 4.61 to 5.03] per 1000 person-years. Correspondingly, 140 of 14 195 patients undergoing TAVI developed IE over a median follow-up of 24.5 months—an overall incidence of 3.57 [95% CI 3.00 to 4.21] per 1000 person-years. The cumulative incidence of IE at 60 months was higher after SAVR than after TAVI (2.4% [95% CI 2.3 to 2.5] vs 1.5% [95% CI 1.3 to 1.8], HR 1.60, p<0.001). Across the entire cohort, SAVR remained an independent predictor of IE after multivariable adjustment. Risk factors for IE included younger age, male sex, atrial fibrillation, and dialysis.

Conclusions

IE is a rare complication of SAVR and TAVI. In our population, the incidence of IE was higher after SAVR than after TAVI.

Infective Endocarditis Caused by Staphylococcus aureus After Transcatheter Aortic Valve Replacement

BACKGROUND

Staphylococcus aureus (SA) has been extensively studied as causative microorganism of surgical prosthetic-valve infective endocarditis (IE). However, scarce evidence exists on SA IE after transcatheter aortic valve replacement (TAVR).

METHODS

Data were obtained from the Infectious Endocarditis After TAVR International Registry, including patients with definite IE after TAVR from 59 centres in 11 countries. Patients were divided into 2 groups according to microbiologic etiology: non-SA IE vs SA IE.

RESULTS

SA IE was identified in 141 patients out of 573 (24.6%), methicillin-sensitive SA in most cases (115/141, 81.6%). Self-expanding valves were more common than balloon-expandable valves in patients presenting with early SA IE. Major bleeding and sepsis complicating TAVR, neurologic symptoms or systemic embolism at admission, and IE with cardiac device involvement (other than the TAVR prosthesis) were associated with SA IE (P < 0.05 for all). Among patients with IE after TAVR, the likelihood of SA IE increased from 19% in the absence of those risk factors to 84.6% if ≥ 3 risk factors were present. In-hospital (47.8% vs 26.9%; P < 0.001) and 2-year (71.5% vs 49.6%; P < 0.001) mortality rates were higher among patients with SA IE vs non-SA IE. Surgery at the time of index SA IE episode was associated with lower mortality at follow-up compared with medical therapy alone (adjusted hazard ratio 0.46, 95% CI 0.22-0.96; P = 0.038).

CONCLUSIONS

SA IE represented approximately 25% of IE cases after TAVR and was associated with very high in-hospital and late mortality. The presence of some features determined a higher likelihood of SA IE and could help to orientate early antibiotic regimen selection. Surgery at index SA IE was associated with improved outcomes, and its role should be evaluated in future studies.

Prosthetic valve endocarditis after transcatheter aortic valve replacement in low-risk patients

OBJECTIVES

We sought to report details of the incidence, organisms, clinical course, and outcomes of prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) in low-risk patients.

BACKGROUND

PVE remains a rare but devastating complication of aortic valve replacement. Data regarding PVE after TAVR in low-risk patients are lacking.

METHODS

We performed a detailed review of all patients in the low-risk TAVR trials who underwent TAVR from 2016 to 2020 and were adjudicated to have definitive PVE by the independent Clinical Events Committee.

RESULTS

We analyzed 396 low-risk patients who underwent TAVR (including 72 with bicuspid valves). PVE occurred in 11 patients at a median 379 days (210, 528) from TAVR. The incidence within the first 30 days was 0%; days 31-365, 1.5%; and after day 365, 2.8%. The most common organism identified was Streptococcus (n = 4/11). Early PVE (≤ 365 days) occurred in five patients, of whom three demonstrated evidence of embolic stroke and two underwent surgical aortic valve re-intervention. Late PVE (> 365 days) occurred in six patients, of whom thee demonstrated evidence of embolic stroke and only one underwent surgical aortic valve re-intervention. Of the six patients with evidence of embolic stroke, two died, two were discharged to rehabilitation, and two were discharged home with home care.

CONCLUSIONS

PVE was infrequent following TAVR in low-risk patients but was associated with substantial morbidity and mortality. Embolic stroke complicated the majority of PVE cases, contributing to worse outcomes in these patients. Efforts must be undertaken to minimize PVE in TAVR.

Bloodstream infections in patients with transcatheter aortic valve replacement

OBJECTIVE

To evaluate incidence and risk factors of bloodstream infections (BSI) in patients with transcatheter aortic valve replacement (TAVR).

METHODS

We conducted a population-based study in southeastern Minnesota using the expanded Rochester Epidemiology Project (e-REP) for all adult (≥18 years) patients who underwent TAVR from January 1, 2010 to December 31, 2018.

RESULTS

The incidence of BSI following TAVR was 1300 episodes/100,000 persons per annum. The median time to BSI following TAVR was 610 days and 84% were community-acquired. Forty percent of BSI cases developed infective endocarditis. Viridans group streptococci (VGS) were the most common pathogens and 80% of patients with VGS BSI had IE.

CONCLUSIONS

The high incidence of BSI among TAVR patients is alarming and is likely due to advanced age and comorbid conditions. Because 40% of BSI patients also developed IE, further investigation of modifiable risk factors associated with BSI is warranted.

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.

METHODS

Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).

RESULTS

A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).

CONCLUSIONS

Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.

Prevention and management of endocarditis after transcatheter pulmonary valve replacement: current status and future prospects

Introduction: Transcatheter pulmonary valve replacement (TPVR) has become an important tool in the management of congenital heart disease with abnormalities of the right ventricular outflow tract. Endocarditis is one of the most serious adverse long-term outcomes and among the leading causes of death in patients with congenital heart disease and after (TPVR).Areas covered: This review discusses the current state knowledge about the risk factors for and outcomes of endocarditis after transcatheter pulmonary valve replacement in patients with congenital and acquired heart disease. It also addresses practical measures for mitigating endocarditis risk, as well as diagnosing and managing endocarditis when it does occur.Expert opinion: With increasing understanding of the risk factors for and management and outcomes of endocarditis in patients who have undergone TPVR, we continue to learn how to utilize TPVR most effectively in this complex population of patients.