Infectious Endocarditis After Transcatheter Aortic Valve Replacement: Epidemiology and Outcomes

Transcatheter heart valve explant with infective endocarditis-associated prosthesis failure and outcomes: the EXPLANT-TAVR international registry

BACKGROUND AND AIMS

Surgical explantation of transcatheter heart valves (THVs) is rapidly increasing, but there are limited data on patients with THV-associated infective endocarditis (IE). This study aims to assess the outcomes of patients undergoing THV explant for IE.

METHODS

All patients who underwent THV explant between 2011 and 2022 from 44 sites in the EXPLANT-TAVR registry were identified. Patients with IE as the reason for THV explant were compared to those with other mechanisms of bioprosthetic valve dysfunction (BVD).

RESULTS

A total of 372 patients from the EXPLANT-TAVR registry were included. Among them, 184 (49.5%) patients underwent THV explant due to IE and 188 (50.5%) patients due to BVD. At the index transcatheter aortic valve replacement, patients undergoing THV explant for IE were older (74.3 ± 8.6 vs. 71 ± 10.6 years) and had a lower Society of Thoracic Surgeons risk score [2.6% (1.8-5.0) vs. 3.3% (2.1-5.6), P = .029] compared to patients with BVD. Compared to BVD, IE patients had longer intensive care unit and hospital stays (P < .05) and higher stroke rates at 30 days (8.6% vs. 2.9%, P = .032) and 1 year (16.2% vs. 5.2%, P = .010). Adjusted in-hospital, 30-day, and 1-year mortality was 12.1%, 16.1%, and 33.8%, respectively, for the entire cohort, with no significant differences between groups. Although mortality was numerically higher in IE patients 3 years postsurgery (29.6% for BVD vs. 43.9% for IE), Kaplan-Meier analysis showed no significant differences between groups (P = .16).

CONCLUSIONS

In the EXPLANT-TAVR registry, patients undergoing THV explant for IE had higher 30-day and 1-year stroke rates and longer intensive care unit and hospital stays. Moreover, patients undergoing THV explant for IE had a higher 3-year mortality rate, which did not reach statistical significance given the relatively small sample size of this unique cohort and the reduced number of events.

Infective Endocarditis-Update for the Perioperative Clinician

Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considerations for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.

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.

Post-Transcatheter Aortic Valve Replacement Infective Endocarditis Leading to Mitral Anterior Leaflet Perforation: A Case Report

Transcatheter aortic valve replacement(TAVR)-related infective endocarditis is a rare but fatal complication that can lead to mitral valve perforation. The clinical presentation usually includes rapidly progressive heart failure and mitral regurgitation. Transesophageal echocardiogram (TEE) is considered superior to transthoracic echocardiogram (TTE) in delineating the diagnosis of mitral valve perforation. We present a case of a 75-year-old female who had a TAVR for severe aortic stenosis three years ago and presented with new-onset atrial fibrillation and developed rapidly progressive acute decompensated heart failure. A TTE showed echogenic vegetation of the mitral valve with a perforated mitral anterior leaflet and mitral regurgitation. The blood cultures grew Group B Streptococcus, and our patient lacked the risk factors for infective endocarditis, including alcoholism, chronic liver disease, pregnancy, immunosuppression, or malignancy. This article highlights infective endocarditis with an uncommon pathogen in a patient with a prior TAVR that leads to the fatal complication of mitral valve perforation.

Surgery for Aortic Prosthetic Valve Endocarditis in the Transcatheter Era

Objectives: As surgical experience with infective endocarditis following transcatheter aortic valve replacement is scarce, this study compared the perioperative and short-term outcomes of patients suffering from endocarditis following surgical aortic valve replacement and transcatheter aortic valve replacement. Methods: Between January 2013 and December 2020, 468 consecutive patients were admitted to our center for surgery for IE. Among them, 98 were operated on for endocarditis following surgical aortic valve replacement and 22 for endocarditis following transcatheter aortic valve replacement. Results: The median EuroSCORE II (52.1 (40.6–62.0) v/s 45.4 (32.6–58.1), p = 0.207) and STS-PROM (1.8 (1.6–2.1) v/s 1.9 (1.4–2.2), p = 0.622) were comparable. Endocarditis following transcatheter aortic valve replacement accounted for 13.7% of the aortic prosthetic valve endocarditis between 2013 and 2015; this increased to 26.9% in the years 2019 and 2020.Concomitant procedures were performed in 35 patients (29.2%). The operative mortality was 26.5% in the endocarditis following surgical aortic valve replacement group and 9.1% in the endocarditis following transcatheter aortic valve replacement group (p = 0.098). Upon follow-up, survival at 6 months was found to be 98% in the group with endocarditis following surgical aortic valve replacement and 89% in the group with endocarditis following transcatheter aortic valve replacement (p = 0.081). Conclusions: Patients suffering from endocarditis following surgical aortic valve replacement and transcatheter aortic valve replacement present with comparable risk profiles and can be surgically treated with comparable results. Surgery as a curative option should not be rejected even in this intermediate-risk cohort.

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.

Transcatheter aortic valve replacement associated infective endocarditis case series: broadening the criteria for diagnosis is the need of the hour

Background

Transcatheter valve replacement (TAVR) is an important therapeutic intervention for patients with aortic valve stenosis. As TAVR has become available to a broader population, there has been an increase in the number of less common, yet potentially catastrophic, complications. TAVR related infective endocarditis (TAVR-IE) is a rare, but potentially fatal, complication.

Case series

We present here two patients that we encountered for TAVR associated infective endocarditis. Our first patient presented 5 weeks after his TAVR. His initial presentation was consistent with signs of sepsis. The patient then developed Mobitz type I block during hospital course. His TEE was negative for features of infective endocarditis. Due to high suspicion, patient was taken for surgical exploration and was found to have multiple foci of vegetation adhered to the stent frame. Our second patient presented with new onset pulmonary edema, worsening heart failure and systemic inflammatory response. A TEE was done for persistent MSSA bacteremia which showed stable prosthetic valve function with no signs of infective endocarditis. Patient was discharged with a prolonged course of intravenous antibiotics. Patient was re-admitted for worsening sepsis and blood cultures were positive for MSSA. Patient was taken for surgical exploration of his prosthetic aortic valve which showed purulent aortic root abscess.

Conclusion

Through these cases, we aim to raise awareness on TAVR-IE. Due to the atypical clinical presentation, the modified Duke criteria may not be sufficient to diagnose TAVR-IE. Transesophageal echocardiogram in TAVR-IE may be negative or indeterminate. Prosthetic valve shadow may obscure smaller vegetations and/or smaller abscesses. A negative transesophageal echocardiogram should not rule out TAVR-IE and further diagnostic imaging modalities should be considered. PET/CT after administration of 18F-FDG (fluorodeoxyglucose) is a useful diagnostic tool in the diagnosis of infective endocarditis where TEE has been negative or inconclusive. Multi-modal imaging, in addition to the modified Duke criteria, can facilitate early diagnosis and improved mortality outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02364-0.

Findings of prosthetic valve endocarditis in the balloon-expandable trans-catheter aortic valve: review of the literature and tips of management

Prosthetic valve endocarditis after transcatheter aortic valve implantation (TAVI) is a rare complication associated with a high mortality rate. Nonetheless, the rapid expansion of TAVI in recent years has proportionally increased the number of patients exposed to the risk of developing transcatheter valve infection. A 71-year-old female with recent history of TAVI was diagnosed with prosthetic valve obstruction secondary to endocarditis. The characteristics of clinical presentation of endocarditis in the balloon-expandable transcatheter valve and the intra-operative findings are discussed with a review of the literature and tips of management.

Infective endocarditis complicated by embolic events: Pathogenesis and predictors

BACKGROUND

Infective endocarditis (IE) continues to be associated with great challenges. Embolic events (EE) are frequent and life-threatening complications in IE patients. It remains challenging to predict and assess the embolic risk in individual patients with IE accurately.

HYPOTHESIS

Accurate prediction of embolization is critical in the early identification and treatment of risky and potentially embolic lesions in patients with IE.

METHODS

We searched the PubMed, Web of Science, and Google Scholar databases using a range of related search terms, and reviewed the literatures about the pathogenesis and embolic predictors of IE.

RESULTS

The development of IE and its complications is widely accepted as the result of complex interactions between microorganisms, valve endothelium, and host immune responses. The predictive value of echocardiographic characteristics is the most powerful for EE. In addition, both easily obtained blood biomarkers such as C-reactive protein, mean platelet volume, neutrophil-to-lymphocyte ratio, anti-β2-glycoprotein I antibodies, D-Dimer, troponin I, matrix metalloproteinases, and several microbiological or clinical characteristics might be promising as potential predictors of EE.

CONCLUSION

Our review provides a synthesis of current knowledge regarding the pathogenesis and predictors of embolism in IE along with a review of potentially emerging biomarkers.

Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis

The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).

Infective Endocarditis After Surgical and Transcatheter Aortic Valve Replacement: A State of the Art Review

Prosthetic valve endocarditis (PVE) after surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) carries significant morbidity/mortality. Our review aims to compare incidence, predisposing factors, microbiology, diagnosis, management, and outcomes of PVE in surgical aortic valve replacement/TAVR patients. We searched PubMed and Embase to identify published studies from January 1, 2015 to March 13, 2020. Key words were indexed for original reports, clinical studies, and reviews. Reports were evaluated by 2 authors against a priori inclusion/exclusion criteria. Studies were included if they reported incidence and outcomes related to surgical aortic valve replacement/TAVR PVE and excluded if they were published pre-2015 or included a small population. We followed the Cochrane methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all stages of the design and implementation. Study quality was based on the Newcastle-Ottawa Scale. Thirty-three studies with 311 to 41 025 patients contained relevant information. The majority found no significant difference in incidence of surgical aortic valve replacement/TAVR PVE (reported as 0.3%-1.2% per patient-year versus 0.6%-3.4%), but there were key differences in pathogenesis. TAVR has a specific set of infection risks related to entry site, procedure, and device, including nonstandardized protocols for infection control, valve crimping injury, paravalvular leak, neo-leaflet stress, intact/calcified native leaflets, and intracardiac hardware. With the expansion of TAVR to lower risk and younger patients, a better understanding of pathogenesis, patient presentation, and guideline-directed treatment is paramount. When operative intervention is necessary, mortality remains high at 20% to 30%. Unique TAVR infection risks present opportunities for PVE prevention, therefore, further investigation is imperative.

New approach to managing infective endocarditis

Despite significant diagnostic and therapeutic improvements, infective endocarditis (IE) still carries high morbidity and mortality. In the last three decades, significant variations in epidemiological and clinical profile of IE have been observed. The diagnosis of IE requires an adequate clinical suspicion, given its pleomorphic presentation. Microbiological and imaging techniques, which are pivotal in confirming the diagnosis, need constant refinement because of suboptimal accuracy. A clinically integrated multidisciplinary approach is recommended. Guidelines provide useful support despite being based mainly on the opinion of experts rather than on randomized trials, with some inconsistencies among different recommendations. This review encounters the current state of knowledge, gaps in evidence, and future research direction in the field of IE.