Prosthetic Valve Endocarditis After TAVR and SAVR: Insights From the PARTNER Trials

The emerging challenge of Enterococcus faecalis endocarditis after transcatheter aortic valve implantation: time for innovative treatment approaches

SUMMARYInfective endocarditis (IE) is a life-threatening infection that has nearly doubled in prevalence over the last two decades due to the increase in implantable cardiac devices. Transcatheter aortic valve implantation (TAVI) is currently one of the most common cardiac procedures. TAVI usage continues to exponentially rise, inevitability increasing TAVI-IE. Patients with TAVI are frequently nonsurgical candidates, and TAVI-IE 1-year mortality rates can be as high as 74% without valve or bacterial biofilm removal. Enterococcus faecalis, a historically less common IE pathogen, is the primary cause of TAVI-IE. Treatment options are limited due to enterococcal intrinsic resistance and biofilm formation. Novel approaches are warranted to tackle current therapeutic gaps. We describe the existing challenges in treating TAVI-IE and how available treatment discovery approaches can be combined with an in silico "Living Heart" model to create solutions for the future.

Epidemiological and microbial trends of infective endocarditis in western Norway: a 7-year prospective observational study

BACKGROUND

In this prospective, observational study, we aimed to investigate epidemiologic and microbial trends of infective endocarditis in western Norway.

METHODS

Clinical and microbiological characteristics of 497 cases of infective endocarditis from 2016 through 2022 were investigated. Categorical data were analysed using Chi-squared tests. Survival data were analysed using multiple Cox regression and reported using hazard ratios.

RESULTS

The mean age was 67 years, and 74% were men. The annual incidence rates varied from 10.4 to 14.1 per 100,000 inhabitants per year. Infective endocarditis on native valves was observed in 257 (52%) of the cases, whereas infective endocarditis on prosthetic valves and/or cardiac implantable electronic devices was observed in 240 (48%) of the cases: infection on surgically implanted bioprostheses was observed in 124 (25%) of the patients, infection on transcatheter aortic valve implantation was observed in 47 (10%) patients, and infection on mechanical valves was observed in 34 (7%) cases. Infection related to cardiac implantable electronic devices was observed in a total of 50 (10%) cases. Staphylococcus aureus and viridans streptococci were the most common microbial causes, and isolated in 145 (29%) and 130 (26%) of the cases, respectively. Enterococcal endocarditis showed a rising trend during the study period and constituted 90 (18%) of our total cases of infective endocarditis, and 67%, 47%, and 26% of the cases associated with prosthetic material, transcatheter aortic valve implantation and cardiac implantable electronic devices, respectively. There was no significant difference in 90-day mortality rates between the native valve endocarditis group (12%) and the group with infective endocarditis on prosthetic valves or cardiac implants (14%), p = 0.522. In a model with gender, age, people who inject drugs, microbiology and type of valve affected, only advanced age was significantly associated with fatal outcome within 90 days.

CONCLUSIONS

The incidence of infective endocarditis, and particularly enterococcal endocarditis, increased during the study period. Enterococci appeared to have a particular affinity for prosthetic cardiac material. Advanced age was the only independent risk factor for death within 90 days.

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.

Emerging and Re-Emerging Pathogens in Valvular Infective Endocarditis: A Review

Infective endocarditis (IE) is a microbial infection of the endocardial surface, most commonly affecting native and prosthetic valves of the heart. The epidemiology and etiology of the disease have evolved significantly over the last decades. With a growing elderly population, the incidence of degenerative valvopathies and the use of prosthetic heart valves have increased, becoming the most important predisposing risk factors. This change in the epidemiology has caused a shift in the underlying microbiology of the disease, with Staphylococci overtaking Streptococci as the main causative pathogens. Other rarer microbes, including Streptococcus agalactiae, Pseudomonas aeruginosa, Coxiella burnetti and Brucella, have also emerged or re-emerged. Valvular IE caused by these pathogens, especially Staphylococcus aureus, is often associated with a severe clinical course, leading to high rates of morbidity and mortality. Therefore, prompt diagnosis and management are crucial. Due to the high virulence of these pathogens and an increased incidence of antimicrobial resistances, surgical valve repair or replacement is often necessary. As the epidemiology and etiology of valvular IE continue to evolve, the diagnostic methods and therapies need to be progressively advanced to ensure satisfactory clinical outcomes.

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.

Clinical Profiles and Outcomes of Prosthesis-Specific Infective Endocarditis Subsequent to Transcatheter Versus Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Prosthetic valve endocarditis (PVE) is a rare but serious complication following aortic valve replacement using either a transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). This study aims to review the profiles and outcomes of PVE after surgical versus transcatheter aortic valve replacement. Electronic searches were performed on Scopus, EMBASE, and PubMed to retrieve related articles. To be included, study designs had to be randomized controlled trials (RCT) or observational cohort studies (in English) with PVE patients that compared differences based on TAVI or SAVR. This review included data for 13,221 patients with PVE diagnoses. Of those, 2,109 patients had an initial SAVR, and 11,112 patients had an initial TAVI. There was no difference in the incidence of PVE in patients who had initial TAVI versus SAVR (1.05% versus 1.01% per person-year, p=0.98). However, the onset of early PVE was more frequently observed in the TAVI group (risk ratio (RR): 1.54, 95% confidence interval (CI) [1.14, 2.08], p=0.005). Patients in the TAVI group had a lower indication for surgery to treat PVE when compared to SAVR (RR: 0.55, 95%CI [0.44, 0.69], p<0.001). Staphylococcus aureus was more likely to be the source of PVE in patients who had previous TAVI (RR: 1.34, 95%CI [1.17, 1.54], p<0.001). Also, Enterococcus faecalis was more frequently observed as a cause of PVE in the TAVI group (RR: 1.49, 95%CI [1.21, 1.82], p<0.001). Patients who underwent SAVR and TAVI had similar incidences of PVE. However, patients who underwent SAVR had a greater indication for surgery to treat PVE, while those who underwent TAVI had higher comorbidities, a higher likelihood of early PVE, and a trend towards higher one-year mortality.

Infective endocarditis after isolated aortic valve replacement: comparison between catheter-interventional and surgical valve replacement

BACKGROUND AND AIMS

Prosthetic valve endocarditis (PVE) is the prognostically most unfavourable complication after aortic valve replacement. This study aims to contribute to a better understanding of the different pathological and therapeutical aspects between PVE following surgical (SAVR) and transcatheter aortic valve replacement (TAVI).

METHODS

All patients who had undergone primary isolated SAVR (n = 3447) or TAVI (n = 2269) at our Centre between 01/2012 and 12/2018 were analysed. Diagnosis of PVE was based on Duke criteria modified in 2015. Incidence, risk factors, pathogens, impact of complications or therapy on mortality were analysed and compared between SAVR- and TAVI-PVE.

RESULTS

PVE incidence did not differ significantly after SAVR with 4.9/100 patient-years and TAVI with 2.4/100 patient-years (p = 0.49), although TAVI patients were older (mean 80 vs. 67 years) and had more comorbidities (STS score mean 5.9 vs. 1.6) (p < 0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than without polymer (HR 4.3; p = 0.004). Most common pathogens were staphylococci and enterococci (p > 0.05). Propensity-score matching analysis showed that the type of aortic valve replacement had no effect on the development of post-procedural PVE (p = 0.997). One-year survival was higher in TAVI-PVE patients treated with antibiotics only compared to additional surgical therapy (90.9% vs. 33.3%; p = 0.005). In SAVR-PVE patients, both therapies were comparable in terms of survival (p = 0.861). However, SAVR-PVE patients who were not operated, despite ESC-guideline recommendation, had significantly poorer one-year survival (p = 0.004).

CONCLUSION

TAVI patients did not have a significantly higher risk to develop PVE. Our data suggest that TAVI-PVE patients in contrast to SAVR-PVE patients can more often be treated with antibiotics only, presumably due to the lack of a polymeric suture ring.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Contemporary applications of multimodality imaging in infective endocarditis

INTRODUCTION

Infective endocarditis (IE) is an increasingly important condition with significant morbidity and mortality. With advancements in cardiovascular interventions including prosthetic valve implantation and utilization of intracardiac devices, the prevalence of IE is rising in the modern era. Early detection and management of this condition are critical.

AREAS COVERED

This review presents a contemporary review of the applications of multi-modality imaging in IE, taking a comparative approach of the various imaging modalities.

EXPERT OPINION

Transthoracic and transesophageal echocardiography are essential imaging modalities in establishing the diagnosis of IE, as well as evaluating for complications of IE. Other imaging modalities such as cardiac computed tomography and nuclear imaging play an important role as adjuvant imaging modalities for the evaluation of IE, particularly in prosthetic valve IE and cardiovascular implantable device associated IE. It is crucial to understand the strengths, weaknesses, and clinical application of each imaging modality, to improve the diagnosis, management, and outcomes of patients with IE.

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.

Patients with Artificial Heart Valves

BACKGROUND

In Germany, a total of 38 547 heart valve procedures were performed in 2022. With a growing number of patients undergoing the surgical and interventional implantation of heart valves, the incidence of prosthetic endocarditis is also rising.

METHODS

We summarize the current state of the prophylaxis, diagnosis, and treatment of prosthetic endocarditis in a selective review of the literature.

RESULTS

Prosthetic endocarditis accounts for 10-30% of all cases of endocarditis. As its echocardiographic and microbiologic findings are often less specific than those of native endocarditis, its diagnosis now increasingly relies on alternative imaging modalities such as F-18-FDG PET-CT. Anti-infective and surgical treatment are made more difficult by biofilm formation on the prosthetic valve and the frequent formation of perivalvular abscesses.

CONCLUSION

Increased awareness of this clinical entity in the outpatient setting will promote the earlier initiation of appropriate diagnostic studies. Proper diagnostic evaluation is an essential prerequisite for the early detection and timely treatment of prosthetic endocarditis, with the goal of preventing progressive destruction and thus improving the outcome. Preventive and educative measures should be intensified, and certified, multidisciplinary endocarditis teams should be established. Antibiotic prophylaxis is now given much more restrictively than in earlier years; the risk of infection must be weighed against the potential development of both individual and collective resistance to antibiotic drugs.

Infective endocarditis after surgical aortic or mitral valve replacement: A nationwide population-based study

OBJECTIVE

Evidence regarding the incidence of prosthetic valve endocarditis and its association with the use of mechanical or biologic prosthetic valves is limited.

METHODS

Patients who underwent aortic or mitral valve replacement in the years 2000 to 2017 were identified from Taiwan's National Health Insurance Research Database and grouped according to the type of prosthesis used (mechanical or biologic). Propensity score matching was performed to reduce confounding.

RESULTS

A total of 22,844 patients were included, with 11,950 (52.2%) and 10,934 (47.8%) in the mechanical prosthesis and biologic prosthesis groups, respectively. After matching, each group contained 5441 patients. During follow-up, patients with a biologic prosthesis had a significantly higher risk of infective endocarditis (IE) than those with a mechanical valve (3.4% vs 1.9%; subdistribution hazard ratio, 1.78; 95% CI, 1.40-2.26). Moreover, biologic prostheses were associated with greater risks of all-cause mortality and redo valve surgery, but lesser risks of ischemic stroke, hemorrhagic stroke, major bleeding, and gastrointestinal bleeding. In subgroup analysis, biologic prostheses were consistently associated with a greater risk of IE in all subgroups, specifically single-valve replacement-aortic, single-valve replacement-mitral, double-valve replacement, active IE (IE diagnosed during index hospitalization), any IE (active or old), and not having a history of IE.

CONCLUSIONS

In this nationwide population-based retrospective cohort study, biologic prosthesis use was associated with a greater risk of IE during follow-up compared with mechanical valve use. However, mechanical valve use was associated with a greater risk of ischemic stroke and hemorrhagic complications.

Contemporary Features and Management of Endocarditis

Infective endocarditis is a rare but devastating disease. Morbidity and mortality rates have failed to improve despite new technological advances. The disease has evolved over time with new significant populations at risk-most notably those with prosthetic valves or implantable cardiovascular devices. These devices pose new challenges for achieving a timely and accurate diagnosis of infection. While the modified Duke criteria is accepted as the gold standard for diagnosing native valve endocarditis, it has been shown to have significantly inferior sensitivity when it comes to identifying infections related to right-heart endocarditis, prosthetic valves, and indwelling cardiac devices. Additionally, prosthetic valves and cardiovascular implantable electronic devices can exhibit shadowing and artifact, rendering transthoracic echocardiography and transesophageal echocardiography results inconclusive or even normal. Having a keen awareness of the varying clinical presentations, as well as emerging valvular imaging modalities such as F-fluorodeoxyglucose cardiac positron-emission tomography plus computed tomography, promises to improve the evaluation and diagnosis of infective endocarditis. However, indications for appropriate use of these studies and guidance on modern clinical management are still needed.

Temporal trends in the incidence of infective endocarditis in patients with a prosthetic heart valve

OBJECTIVE

The incidence of infective endocarditis (IE) is increasing, as is the insertion of prosthetic heart valves. We aimed to examine nationwide temporal trends in the incidence of IE in patients with a prosthetic heart valve in Denmark from 1999 to 2018.

METHODS

Using the Danish nationwide registries, we identified patients who underwent heart valve implantation (for other reasons than IE) between 1999 and 2018. Crude incidence rates of IE per 1000 person-years (PY) were computed in 2-year intervals. IE incidences were compared using sex-adjusted and age-adjusted incidence rate ratios (IRR) using Poisson regression across calendar periods (1999-2003, 2004-2008, 2009-2013, and 2014-2018).

RESULTS

We identified 26 604 patients with first-time prosthetic valve implantation (median age 71.7 years (IQR 62.7-78.0), 63% males). The median follow-up time was 5.4 years (IQR 2.4-9.6). Patients in the time period 2014-2018 were older (median age of 73.9 years (66.2:80.3)), and with a higher burden of comorbidities compared with the time period 1999-2003 (median age of 67.9 years (58.3:74.5)) at the time of implantation. A total of 1442 (5.4%) patients developed IE. The lowest IE incidence rate was 5.4/1000 PY (95% CI 3.9 to 7.4) in 2001-2002, and the highest incidence rate was 10.0/1000 PY (95% CI 8.8 to 11.1) in 2017-2018 with an unadjusted increase during the study period (p=0.003). We found an adjusted IRR of 1.04 (95% CI 1.02 to 1.06) (p<0.0007) per two calendar-years increments. Age-adjusted IRR for men were 1.04 (95% CI 1.01 to 1.07) (p=0.002) per two calendar years increment, and for women 1.03 (95% CI 0.99 to 1.07) (p=0.12), with p=0.32 for interaction.

CONCLUSION

In Denmark, the incidence of IE increased during the last 20 years in patients with prosthetic heart valves.

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 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.

Surgical Outcomes After Reconstruction of the Aortomitral Curtain

Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

Infective endocarditis (IE) is a life-threatening microbial infection of native and prosthetic heart valves, endocardial surface, and/or indwelling cardiac device. Prevalence of IE is increasing and mortality has not significantly improved despite technological advances. This review provides an updated overview using recent literature on the clinical presentation, diagnosis, imaging, causative pathogens, treatment, and outcomes in native valve, prosthetic valve, and cardiac device-related IE. In addition, the experimental approaches used in IE research to improve the understanding of disease mechanisms and the current diagnostic pipelines are discussed, as well as potential innovative diagnostic and therapeutic strategies. This will ultimately help towards deriving better diagnostic tools and treatments to improve IE patient outcomes.

Surgical explantation of failed transcatheter heart valves: indications and results

Given the recent surge in transcatheter heart valve replacement (THVR), cardiac surgeons will surely face the challenge of eventual explantation. The aim of this study was to determine indications for reoperation, while exploring pertinent technical aspects and survival after THV explantation in a cohort originally deemed high risk or even inoperable. Between February 2008 and March 2019, 31 patients with failed transcatheter aortic valve replacement (TAVR) underwent surgical explantations at our facility. Data were prospectively collected for retrospective analysis of procedural indications, technical issues, and postoperative survival. The major reason for TAVR removal was bioprosthetic valve failure (BVF) due to infective endocarditis (IE: 16/31 [51.6%]), non-structural (NSVD: 14/31 [45.2%]) and structural (SVD: 1/31 [3.2%]) valve deterioration accounting for the rest. Mean age at THV explantation was 76.3 ± 8.3 years, and median time from TAVR to explantation was 153 days (0 days-56.6 months). Median ICU and hospital stay were 6 days (1-44 days) and 23 days (8-62 days), respectively. Thirty-day and 1-year survival rates were 74.2% and 67.2%, respectively. Median follow-up interval after explantation was 364 days (3 days-80 months). Mean cardiopulmonary bypass time was 124.6 ± 46.8 min, and mean aortic cross-clamp time was 84.3 ± 32.9 min. There was no need for unplanned aortic root repair owing to tissue damage during dissection of the TAVR from surrounding tissue. The most common reason for THV explantation was (a) BVF for IE and (b) BVF secondary to NSVD. Although 30-day and 1-year mortality rates in this multimorbid cohort were predictably high, no procedural mortalities occurred.

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.

Transcatheter aortic valve implantation-related infective endocarditis: experience from an Irish tertiary referral centre

BACKGROUND

Transcatheter aortic valve implantation-related infective endocarditis (TAVI-IE) is a well-recognised and serious complication following TAVI. The purpose of this study was to describe the clinical characteristics, microorganism spectrum, and outcomes of TAVI-IE in an Irish context.

METHODS

A prospective registry was used to assess the baseline demographics, procedural variables, and clinical outcomes of patients undergoing TAVI between 2009 and 2020 at two tertiary referral Irish Hospitals.

RESULTS

A total of 733 patients underwent TAVI during the study period. During a follow-up duration of 1,949 person-years (median 28 months), TAVI-IE occurred in 17 (2.3%) patients. The overall incidence was 0.87 per 100 person-years and the median time from TAVI to presentation with IE was 7 months [IQR: 5-13 months]. In those who developed TAVI-IE, the mean age was 78.7 years, 70.5% were male, and there was a trend towards more permanent pacemaker implantations post-TAVI (17.6% vs. 5.86%; p = 0.08). The dominant culprit microorganisms were streptococci (41.1%) and four (23.5%) cases were attributed to dental seeding. Major complications of TAVI-IE included one (5.8%) stroke, one (5.8%) in-hospital death, and two (11.7%) urgent surgical aortic valve replacements. The Kaplan-Meier estimate of survival at 1-year was 82% (95% CI = 55-95).

CONCLUSIONS

This Irish cohort of TAVI-IE exhibited a similar incidence and time to presentation compared to prior international registries; however, the 1-year mortality rate was comparatively lower. The need for rigorous dental clearance pre-TAVI and maintenance of dental health post-TAVI is underscored by the high prevalence of oral streptococcus species in this cohort.

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.

Surgery and outcome of infective endocarditis in octogenarians: prospective data from the ESC EORP EURO-ENDO registry

PURPOSE

High mortality and a limited performance of valvular surgery are typical features of infective endocarditis (IE) in octogenarians, even though surgical treatment is a major determinant of a successful outcome in IE.

METHODS

Data from the prospective multicentre ESC EORP EURO-ENDO registry were used to assess the prognostic role of valvular surgery depending on age.

RESULTS

As compared to < 80 yo patients, ≥ 80 yo had lower rates of theoretical indication for valvular surgery (49.1% vs. 60.3%, p < 0.001), of surgery performed (37.0% vs. 75.5%, p < 0.001), and a higher in-hospital (25.9% vs. 15.8%, p < 0.001) and 1-year mortality (41.3% vs. 22.2%, p < 0.001). By multivariable analysis, age per se was not predictive of 1-year mortality, but lack of surgical procedures when indicated was strongly predictive (HR 2.98 [2.43-3.66]). By propensity analysis, 304 ≥ 80 yo were matched to 608 < 80 yo patients. Propensity analysis confirmed the lower rate of indication for valvular surgery (51.3% vs. 57.2%, p = 0.031) and of surgery performed (35.3% vs. 68.4%, p < 0.0001) in ≥ 80 yo. Overall mortality remained higher in ≥ 80 yo (in-hospital: HR 1.50[1.06-2.13], p = 0.0210; 1-yr: HR 1.58[1.21-2.05], p = 0.0006), but was not different from that of < 80 yo among those who had surgery (in-hospital: 19.7% vs. 20.0%, p = 0.4236; 1-year: 27.3% vs. 25.5%, p = 0.7176).

CONCLUSION

Although mortality rates are consistently higher in ≥ 80 yo patients than in < 80 yo patients in the general population, mortality of surgery in ≥ 80 yo is similar to < 80 yo after matching patients. These results confirm the importance of a better recognition of surgical indication and of an increased performance of surgery in ≥ 80 yo patients.

Very early infective endocarditis after transcatheter aortic valve replacement

BACKGROUND

Scarce data exist about early infective endocarditis (IE) after trans-catheter aortic valve replacement (TAVR).

OBJECTIVE

The objective was to evaluate the characteristics, management, and outcomes of very early (VE) IE (≤ 30 days) after TAVR.

METHODS

This multicenter study included a total of 579 patients from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR.

RESULTS

Ninety-one patients (15.7%) had VE-IE. Factors associated with VE-IE (vs. delayed IE (D-IE)) were female gender (p = 0.047), the use of self-expanding valves (p < 0.001), stroke (p = 0.019), and sepsis (p < 0.001) after TAVR. Staphylococcus aureus was the main pathogen among VE-IE patients (35.2% vs. 22.7% in the D-IE group, p = 0.012), and 31.2% of Staphylococcus aureus infections in the VE-IE group were methicillin-resistant (vs. 14.3% in the D-IE group, p = 0.001). The second-most common germ was enterococci (34.1% vs. 24.4% in D-IE cases, p = 0.05). VE-IE was associated with very high in-hospital (44%) and 1-year (54%) mortality rates. Acute renal failure following TAVR (p = 0.001) and the presence of a non-enterococci pathogen (p < 0.001) were associated with an increased risk of death.

CONCLUSION

A significant proportion of IE episodes following TAVR occurs within a few weeks following the procedure and are associated with dismal outcomes. Some baseline and TAVR procedural factors were associated with VE-IE, and Staphylococcus aureus and enterococci were the main causative pathogens. These results may help to select the more appropriate antibiotic prophylaxis in TAVR procedures and guide the initial antibiotic therapy in those cases with a clinical suspicion of IE. Very early infective endocarditis after trans-catheter aortic valve replacement. VE-IE indicates very early infective endocarditis (≤30 days post TAVR). D-IE indicates delayed infective endocarditis.

Treatment of Bicuspid Aortic Valve Stenosis with TAVR: Filling Knowledge Gaps Towards Reducing Complications

PURPOSE OF REVIEW

Bicuspid aortic valve (BAV) disease is the most common congenital heart defect worldwide. When severe, symptomatic aortic stenosis ensues, the treatment has increasingly become transcatheter aortic valve replacement (TAVR). The purpose of this review is to identify BAV classification and imaging methods, outline TAVR outcomes in BAV anatomy, and discuss how computational modeling can enhance TAVR treatment in BAV patients.

RECENT FINDINGS

TAVR use in BAV patients, when compared to use in tricuspid aortic valves, showed lower device success rate, and there remains no long-term randomized trial data. It has been reported that BAV patients with severe calcification increase the rate of complications. Additionally, the asymmetrical morphology of BAVs often results in asymmetric stent geometries which have implications for increased thrombosis risk and decreased durability. These adverse outcomes are currently very difficult to predict from routine pre-procedural imaging alone. Recently developed patient specific experimental and computational techniques have the potential to assist in filling knowledge gaps in the mechanisms of these complications and provide more information during preclinical planning for better TAVR selection in low surgical risk BAV patients. Efficacy of TAVR for irregular BAV anatomies remains concerning due to the lack of a long-term randomized trial data, their increased rate of short-term complications, and signs that long-term durability could be an issue. More knowledge on identifying which BAV anatomies are at greater risk for these adverse outcomes can potentially improve patient selection for TAVR versus SAVR in low surgical risk BAV patients.

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.

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.

Cardiac Operations after Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience.

METHODS

From 1/2012-7/2020, 59 patients (median age 70) underwent cardiac operations after TAVR, 38 (64%) of the latter performed outside our center. Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at time of prior TAVRs and at applicable index cardiac operations.

RESULTS

From 2012-2018, there were fewer than 10 operations after TAVR, but 18 in 2019. Interval between prior TAVR and cardiac surgery decreased exponentially from 7 to less than 1 year over the experience. In applicable cases (n=19; 32%), median STS-PROM was 5.5% (15^th-85th percentiles, 3.1%-25%); 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical AVRs. TAVR valve stenosis/regurgitation (n=34; 58%) was the leading indication, followed by paravalvular leak (14; 24%) and endocarditis (n=10/17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative mortality was 5 (8.5%), postoperative stroke 2 (3.4%), and postoperative dialysis 6 (10%).

CONCLUSIONS

Cardiac operations after TAVR are increasing and interval between TAVR and operation decreasing. Most cardiac operations are complex, high-risk reoperations and isolated AVR rare. These findings should be considered when TAVR is selected for low-intermediate risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.

Incidence and Outcomes of Infective Endocarditis After Transcatheter or Surgical Aortic Valve Replacement

Background

Data comparing the frequency and outcomes of infective endocarditis (IE) after transcatheter (TAVR) to surgical aortic valve replacement (SAVR) are scarce. The objective of this study is to compare the incidence and outcomes of IE after TAVR using a supra‐annular, self‐expanding platform (CoreValve and Evolut) to SAVR.

Methods and Results

Data of 3 randomized clinical trials comparing TAVR to SAVR and a prospective continued TAVR access study were pooled. IE was defined on the basis of the modified Duke criteria. The cumulative incidence of IE was determined by modeling the cause‐specific hazard. Estimates of all‐cause mortality were calculated by means of the Kaplan–Meier method. Outcomes are reported for the valve‐implant cohort. During a mean follow‐up time of 2.17±1.51 years, 12 (0.5%) of 2249 patients undergoing TAVR and 21 (1.1%) of 1828 patients undergoing SAVR developed IE. Patients with IE more frequently had diabetes mellitus than those without (57.6% versus 34.2%; P=0.005). The cumulative incidence of IE was 1.01% (95% CI, 0.47%–1.96%) after TAVR and 1.58% (95% CI, 0.97%–2.46%) after SAVR (P=0.047) at 5 years. Among patients with IE, the rate of all‐cause mortality was 27.3% (95% CI, 1.0%–53.6%) in the TAVR and 51.8% (95% CI, 28.2%–75.3%) in the SAVR group at 1 year (log‐rank P=0.15).

Conclusions

Pooled prospectively collected data comparing TAVR with a supra‐annular, self‐expanding device to SAVR showed a low cumulative risk of IE irrespective of treatment modality, although the risk was lower in the TAVR implant group. Once IE occurred, mortality was high.

Registration

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01240902, NCT01586910, NCT02701283.

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.

Multimodality imaging in the diagnosis and management of prosthetic valve endocarditis: A contemporary narrative review

Infective endocarditis is one of the leading life-threatening infections around the world. With the exponential growth in the field of transcatheter interventions and advances in specialized surgical techniques, the number of prosthetic valves and cardiac implantable devices has significantly increased. This has led to a steep rise in the number of cases of prosthetic valve endocarditis (PVE) comprising up to 30% of all cases. Clinical guidelines rely on the use of the modified Duke criteria; however, the diagnostic sensitivity of the modified Duke criteria is reduced in the context of PVE. This is in part attributed to prosthesis related artifact which greatly affects the ability of echocardiography to detect early infective changes related to PVE in certain cases. There has been increasing recognition of the roles of complementary imaging modalities and updates in international society recommendations. Prompt diagnosis and treatment can prevent the devastating consequences of this condition. Imaging modalities such as cardiac computed tomography and ¹⁸-fluorodeoxyglucose positron emission tomography/computed tomography are diagnostic tools that provide a complementary role to echocardiography in aiding diagnosis, pre-operative planning, and treatment decision-making process in these challenging cases. Understanding the strengths and limitations of these adjuvant imaging modalities is crucial for the implementation of appropriate imaging modalities in clinical practice.

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.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

An 80-Year-Old Man With Persistent Enterococcus faecalis Bacteremia

CASE PRESENTATION

An 80-year old man presented to the ED after being found down in his home. He had gone to the restroom to perform straight catheterization, as he normally does for his enlarged prostate, and was found slumped over and confused. On arrival to the ED, he was found to be in atrial fibrillation with rapid ventricular response, febrile, and hypotensive. CT imaging of his head, chest, and abdomen-pelvis was obtained. He was started on broad-spectrum antibiotics and norepinephrine infusion for presumed urinary septic shock and admitted to the medical critical care unit for further management.

Cardiac surgery following transcatheter aortic valve replacement

OBJECTIVES

The objective of this study was to retrospectively analyse surgical outcomes of patients undergoing secondary cardiac surgery after initial transcatheter aortic valve replacement (TAVR).

METHODS

Between December 2012 and February 2020, a total of 41 consecutive patients underwent cardiac surgery after a TAVR procedure at our institution. Patients who underwent emergency operations due to periprocedural complications such as ventricular rupture and TAVR dislocation were excluded from this study (n = 12). Thus, 29 patients were included in the analysis. Data are presented as medians (25th-75th quartiles) or as absolute numbers (percentages).

RESULTS

The median age was 76 years (68-80); 58.6% were men. The median time to a secondary conventional procedure was 23 months (8-40), with 8 patients requiring surgical intervention within the first year post TAVR. The indications for secondary conventional procedures were prosthesis endocarditis (n = 15), prosthesis degeneration or dysfunction (n = 7) and progression of valvular, aortic or coronary artery disease (n = 7). Surgical redo aortic valve replacement was performed in 24 patients (82.8%). No complications involving the aortic root or the aortomitral continuity were observed. The operative mortality was 10.3%. Extracorporeal life support was required in 3 patients (10.3%) for a median duration of 3 days (3-3 days). No adverse cerebrovascular events were observed postoperatively. Postoperatively, 4 patients (13.8%) required a pacemaker and 7 patients (24.1%) required renal replacement therapy. Overall survival at 1 year was 83.0%.

CONCLUSIONS

Conventional cardiac surgical procedures following TAVR are feasible with reasonable results and a low complication rate.

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.

Echocardiographic evaluation of paravalvular aortic regurgitation of a patient with recurrent aortic valve replacements

Paravalvular regurgitation (PVR) is a serious complication after surgical valve replacement. Echocardiography is the gold standard technique to assess the severity of PVR with an integrated approach. A 48-year-old male underwent aortic valve replacement due to infective endocarditis (IE). During in-hospital cardiac rehabilitation after a redo surgery for a new IE three years later, an echo-free anterior space around the valve with several PVRs through transthoracic echocardiography (TTE) was identified. On transesophageal echocardiography (TOE) a double PVR (anterior and posterior) with abscessual cavity was detected. The patient's conditions worsened within six months with hemodynamic instability: a massive PVR due to a large abscess cavity next to the right cusp was confirmed by TTE and TOE and a third surgery was carried out. On the third admission at our Rehabilitation Unit the echo features were normal. Patient did not report any cardiovascular symptoms at 1 year follow-up.