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

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.

Imaging in Infective Endocarditis-Current Opinions and Trends in Cardiac Computed Tomography

Infective endocarditis is a rare disease with an increasing incidence and an unaltered high mortality rate, despite medical development. Imaging plays an integrative part in the diagnosis of infective endocarditis, with echocardiography as the initial diagnostic test. Research data in the utility of cardiac computed tomography (CCT) in the diagnostic algorithm of IE are rising, which indicates its importance in detection of IE-related lesion along with the exclusion of coronary artery disease. The latest 2023 European Society of Cardiology Guidelines in the management of IE classified CCT as class of recommendation I and level of evidence B in detection of both valvular and paravalvular lesions in native and prosthetic valve endocarditis. This review article provides a comprehensive and contemporary review of the role of CCT in the diagnosis of IE, the optimization of acquisition protocols, the morphology characteristics of IE-related lesions, the published data of the diagnostic performance of CCT in comparison to echocardiography as the state-of-art method, as well as the limitations and future possibilities.

Surgical Therapy of Infective Prosthesis Endocarditis following TAVI: A Single Center's Experience

BACKGROUND/OBJECTIVES

Infective prosthesis endocarditis (IE) following transcatheter aortic valve implantation (TAVI) presents significant management challenges, marked by high mortality rates. This study reviews our center's experience with surgical interventions for IE in patients post-TAVI, focusing on outcomes, challenges, and procedural complexities, and providing an overview of the limited literature surrounding this subject.

METHODS

This study was executed as a comprehensive retrospective analysis, targeting the clinical outcomes of surgical treatment in patients presenting with PVE following TAVI procedures at our institution. From July 2017 to July 2022, we identified five patients who had previously undergone transfemoral transcatheter aortic valve implantation and were later diagnosed with PVE needing surgery, strictly adhering to the modified Duke criteria.

RESULTS

All surgical procedures were reported successful with no intra- or postoperative mortality. Patients were predominantly male (80%), with an average age of 76 ± 8.6 years, presenting mostly with dyspnea (NYHA Class II). The mean follow-up was between 121 and 1973 days, with outcomes showing no occurrences of stroke, myocardial infarction, or major bleeding. One patient expired from unrelated causes 3.7 years post-surgery. The operative and postoperative protocols demonstrated effective disease management with enhanced survival and minimal complications.

CONCLUSIONS

The surgical treatment of IE following TAVI, though challenging, can be successfully achieved with careful patient selection and a multidisciplinary approach. The favorable outcomes suggest that surgical intervention remains a viable option for managing this high-risk patient group. Our study also highlights the scarce literature available on this topic, suggesting an urgent need for more comprehensive research to enhance understanding and improve treatment strategies. Future studies with larger cohorts are needed to further validate these findings and refine surgical strategies for this growing patient population.

Haemophilus parainfluenza-Associated Aortic Root Abscess and Septic Embolic Stroke Post-transcatheter Aortic Valve Replacement: A Case Study

We present a rare instance of aortic root abscess and septic embolic stroke due to Haemophilus parainfluenza in a 75-year-old male patient who had undergone a recent transcatheter aortic valve replacement. The patient initially presented with generalized weakness and altered mental status. Blood cultures grew Haemophilus parainfluenza. Brain imaging showed multiple infarcts with some areas of hemorrhagic conversion. Echocardiography demonstrated an aortic root abscess as well as vegetation on the tricuspid valve. Surgical correction was deemed high risk; hence, management involved intravenous (IV) antibiotics, resulting in the resolution of both symptoms and the abscess.

Treatment options for isolated aortic valve insufficiency: a review

Aortic insufficiency (AI) is a valvular disease with increasing prevalence in older patients. The modern era provides numerous options for the management of AI which is explored here. Traditional interventions included aortic valve replacement with either mechanical or bioprosthetic aortic valves. While the former is known for its durability, it has grown out of favor due to the potential complications of anticoagulation. The preference for bioprosthetic valves is thus on the rise, especially with the advancements of transcatheter technology and the use of valve-in-valve therapy. Surgical options are also no longer limited to replacement but include complex techniques such as those required for aortic valve repair, Ozaki neocuspidization, Ross procedure and valve-sparring aortic root repair. Transcatheter options for the management of AI are not commercially available currently; however, preliminary data from ad-hoc trials, showed promising results and potential use of transcatheter technology in a variety of patients with pure AI.

Minimally Invasive and Full Sternotomy Aortic Valve Replacements Lead to Comparable Long-Term Outcomes in Elderly Higher-Risk Patients: A Propensity-Matched Comparison

BACKGROUND

Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population.

METHODS

Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52-93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7-42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs).

RESULTS

FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47-194) vs. 100 (46-246) min (p = 0.039) and 57 (33-156) vs. 69 (32-118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596).

CONCLUSIONS

In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.

Systematic Dental Screening Before Transcatheter Aortic Valve Replacement: A Call to Action!

Transcatheter aortic valve implantation (TAVR) offers an alternative to surgical aortic valve replacement for high-risk patients. Despite its benefits, concerns arise from its association with prosthetic valve endocarditis (PVE), a severe complication. Recent studies indicate a potential higher incidence of PVE in TAVR recipients, especially within the first year postimplantation. A significant proportion of these cases trace back to oral-pharyngeal bacteria. However, no consensus exists on dental screening for TAVR, unlike the standard procedure for surgical aortic valve replacement. Dental screenings could reduce PVE risks and aid in patient recovery. This article underscores the importance of dental screenings, calling for more research to establish its efficacy and systematic application for TAVRI candidates. Collaborative efforts between oral and maxillofacial surgeons and cardiologists are crucial for optimal patient outcomes.

Heart transplantation in a patient with infective endocarditis bridged with Impella 5.5: a case report

Background

Infective endocarditis (IE) is a feared complication after surgical valve replacement accounting for 10% to 30% of all cases of IE. Our case is unique as we present a decompensated heart failure patient with IE who urgently needed mechanical circulatory support (MCS) to stabilize while IE was treated. We used Impella to bridge him to sterile state before heart transplant was done. This case highlights the importance of different strategies for bridge to heart transplant in decompensated heart failure patients with endocarditis.

Case summary

We describe a case of 62-year-old male who initially presented with severe shortness of breath with minimal exertion, weight gain, and lower extremity oedema diagnosed with acute on chronic systolic heart failure (HF) exacerbation (ACC stage D, NYHA class IV). Initial blood cultures and extensive work-up for IE were negative. He continued to decompensate haemodynamically despite inotropic support and the decision was to proceed with durable left ventricular assist device (LVAD) as bridge to orthotopic heart transplantation (OHT). Immediately prior to LVAD implantation, patient's blood cultures became positive for Cutibacterium acnes. Echocardiogram revealed IE on bioprosthetic aortic valve. Patient therefore underwent urgent aortic valve replacement (AVR) and was stabilized with Impella 5.5.

Discussion

We highlight a case where MCS with Impella was used as a bridge to transplant in a decompensated HF patient who was septic. Patient was listed for OHT but was found to be septic due to IE and had to undergo AVR to achieve infection source control prior to undergoing heart transplant. Impella was used effectively to stabilize ACC stage D/NYHA class IV patient while he recovered from AVR and endocarditis before his blood cultures cleared up and he was listed for OHT. He successfully underwent OHT after 3 weeks.

Multimodality Imaging Diagnosis in Infective Endocarditis

Imaging is an important tool in the diagnosis and management of infective endocarditis (IE). Echocardiography is an essential examination, especially in native valve endocarditis (NVE), but its diagnostic accuracy is reduced in prosthetic valve endocarditis (PVE). The diagnostic ability is superior for transoesophageal echocardiography (TEE), but a negative test cannot exclude PVE. Both transthoracic echocardiography (TTE) and TEE can provide normal or inconclusive findings in up to 30% of cases, especially in patients with prosthetic devices. New advanced non-invasive imaging tests are increasingly used in the diagnosis of IE. Nuclear medicine imaging techniques have demonstrated their superiority over TEE for the diagnosis of PVE and cardiac implantable electronic device infective endocarditis (CIED-IE). Cardiac computed tomography angiography imaging is useful in PVE cases with inconclusive TTE and TEE investigations and for the evaluation of paravalvular complications. In the present review, imaging tools are described with their values and limitations for improving diagnosis in NVE, PVE and CIED-IE. Current knowledge about multimodality imaging approaches in IE and imaging methods to assess the local and distant complications of IE is also reviewed. Furthermore, a potential diagnostic work-up for different clinical scenarios is described. However, further studies are essential for refining diagnostic and management approaches in infective endocarditis, addressing limitations and optimizing advanced imaging techniques across different clinical scenarios.

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.

Distant embolisation in infective endocarditis: characteristics and outcomes

BACKGROUND

Infective endocarditis is a severe and potentially lethal cardiac disease. Recognition of the clinical features of endocarditis, such as distant embolisation, and adequate treatment should be initiated promptly given the grim perspective of upcoming virulent pathogens.

METHODS

We report on our registry-based experience with outcomes of consecutive patients with infective endocarditis with distant embolisation. We aimed to describe the patient characteristics of infective endocarditis complicated by distant organ embolisation and the safety aspects of continuing endocarditis treatment at home in these patients.

RESULTS

From November 2018 through April 2022, 157 consecutive patients were diagnosed with infective endocarditis. Of them, 38 patients (24%) experienced distant embolisation, either in the cerebrum (n = 18), a visceral organ (n = 5), the lungs (n = 7) or the myocardium (n = 8). Pathogens identified in blood cultures were predominantly streptococcal variants (43%), with only one culture-negative endocarditis case. Of the 18 patients with cerebral embolisation, 12 had neurological complaints and most often discrete abnormal findings on neurological examination. Six of the 8 cardiac embolism patients experienced chest pain before admission. Visceral organ and pulmonary embolism occurred silently. Of the 38 patients with distant embolisation, 17 could be discharged earlier by providing antibiotic treatment at home without complications.

CONCLUSION

This registry-based single-centre experience showed an incidence of distant embolisation in daily care of 24%. Cerebral and coronary embolisation provoked symptoms, while visceral emboli remained silent. Pulmonary emboli may present with inflammatory signs. Distant embolisation was not in itself a contra-indication for outpatient endocarditis@home treatment.

Transcatheter aortic valve intervention in patients with cancer

The prevalence of concurrent cancer and severe aortic stenosis (AS) is increasing due to an ageing population. In addition to shared traditional risk factors for AS and cancer, patients with cancer may be at increased risk for AS due to off-target effects of cancer-related therapy, such as mediastinal radiation therapy (XRT), as well as shared non-traditional pathophysiological mechanisms. Compared with surgical aortic valve replacement, major adverse events are generally lower in patients with cancer undergoing transcatheter aortic valve intervention (TAVI), especially in those with history of mediastinal XRT. Similar procedural and short-to-intermediate TAVI outcomes have been observed in patients with cancer as compared with no cancer, whereas long-term outcomes are dependent on cancer survival. Considerable heterogeneity exists between cancer subtypes and stage, with worse outcomes observed in those with active and advanced-stage disease as well as specific cancer subtypes. Procedural management in patients with cancer poses unique challenges and thus requires periprocedural expertise and close collaboration with the referring oncology team. The decision to ultimately pursue TAVI involves a multidisciplinary and holistic approach in assessing the appropriateness of intervention. Further clinical trial and registry studies are needed to better appreciate outcomes in this population.

Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis?

Biological valve failure (BVF) is an inevitable condition that compromises the durability of biological heart valves (BHVs). It stems from various causes, including rejection, thrombosis, and endocarditis, leading to a critical state of valve dysfunction. Echocardiography, cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging play pivotal roles in the diagnostic multimodality workup of BVF. By providing a comprehensive overview of the pathophysiology of BVF and the diagnostic approaches in different clinical scenarios, this review aims to aid clinicians in their decision-making process. The significance of early detection and appropriate management of BVF cannot be overstated, as these directly impact patients' prognosis and their overall quality of life. Ensuring timely intervention and tailored treatments will not only improve outcomes but also alleviate the burden of this condition on patients' life. By prioritizing comprehensive assessments and adopting the latest advancements in diagnostic technology, medical professionals can significantly enhance their ability to manage BVF effectively.

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.

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 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.

A Fatal Case of Staphylococcus capitis Endocarditis in a Patient With Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has evolved to become a standard management modality for high-risk, moderate, and even low-risk patients with symptomatic aortic stenosis. Infective endocarditis (IE) after a TAVR is rare and difficult to diagnose. Typical sonographic characteristics observed with an echocardiogram in native valve endocarditis may not be present in TAVR-IE cases. Enterococcal species are identified to be the most frequent causative agents. Coagulase-negative staphylococci (CoNS) can infrequently lead to a fatal course of endocarditis in the TAVR population. There are only seven previously reported cases of Staphylococcus capitis (S. capitis) prosthetic valve endocarditis noted in the literature. Here we present a man in his 60s who presented to our facility for evaluation of fever and shortness of breath. He was subsequently diagnosed with S. capitis TAVR-IE. He was not considered a surgical candidate and was treated medically for IE with a fatal outcome.

Periprosthetic joint infection caused by kytococcus schroeteri: The first reported case and a review of the literature

Oftentimes, Gram-positive cocci are the cause for periprosthetic joint infections (PJI). Most of these infections include bacteria such as Staphylococcus aureus, Staphylococcus epidermidis or other coagulase-negative staphylococci. We here present the first case of a PJI caused by Kytococcus schroeteri. While being a Gram-positive coccus, it is very rarely the cause for infections in the human body. K. schroeteri is part of the micrococcus branch and often encountered as a symbiotic bacterium living on the skin. Regarding its pathogenic potential, not a lot is known since less than a few dozen human infections have been reported worldwide. Furthermore, many of the cases reported are either associated with implanted material, especially heart valves, or associated with patients whose immune response is deficient. Only 3 reports of osteoarticular infections are described so far.

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.

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.

Polyphenol based hybrid nano-aggregates modified collagen fibers of biological valve leaflets to achieve enhanced mechanical, anticoagulation and anti-calcification properties

Glutaraldehyde (Glut)-crosslinked porcine pericardium and bovine pericardium are mainly consisted of collagen and widely used for the preparation of heterogenous bioprosthetic heart valves (BHV), which play an important role in the replacement therapy of severe valvular heart disease, while their durability is limited by degeneration due to calcification, thrombus, endothelialization difficulty and prosthetic valve endocarditis. Herein, we develop a novel BHV, namely, TPly-BP, based on natural tannic acid and polylysine to improve the durability of Glut crosslinked bovine pericardium (Glut-BP). Impressively, tannic acid and polylysine could form nanoaggregates via multiple hydrogen bonds and covalent bonds, and the introduction of nanoaggregates not only improved the mechanical properties and collagen stability but also endowed TPly-BP with good biocompatibility and hemocompatibility. Compared to Glut-BP, TPly-BP showed significantly reduced cytotoxicity, improved endothelial cell adhesion, a low hemolysis ratio and obviously reduced platelet adhesion. Importantly, TPly-BP exhibited great antibacterial and in vivo anti-calcification ability, which was expected to improve the in vivo durability of BHVs. These results suggested that TPly-BP would be a potential candidate for BHV.

Graphical abstract

The role of imaging in infective endocarditis

Infective endocarditis (IE) poses a large diagnostic and therapeutical challenge. An early diagnosis is necessary for a positive outcome. Echocardiography is initial diagnostic method when there is a possibility of IE presence. TTE and TEE are useful in detection, accurate localisation and estimation of vegetation size, and also in detection of paravalvular spreading of infection. In certain situations, there is a need for usage of complementary methods like CCT and nuclear techniques. This article will outline advantages and limitations of certain diagnostic methods in diagnosis of IE.

Managing complications after transcatheter aortic valve implantation

INTRODUCTION

Although transcatheter aortic valve implantation (TAVI) has become a streamlined and standardized procedure, different complications still remain and need the operators to be properly trained about their management.

AREAS COVERED

This review article aims at offering a practical overview of the most impactful TAVI complications, analyzing, and discussing the potential risk factors, and focusing on the available strategies for their management.

EXPERT OPINION

Complications following TAVI have been decreasing thanks to technical advancements and operators experience. The thorough knowledge of potential complications and their prevention played a key role in the decreasing of complications rates. Pre-procedural, computed tomography angiography assessment of patient's anatomical characteristics, allows to properly choose and tailor the best strategy for managing complications in most of cases. Nevertheless, further research is required to shed lights about the optimal strategies to adopt for managing TAVI complications.

FDG PET/CT in Cardiac Infection: Does It Matter? A Narrative Review

The limited performance of echocardiography in specific infectious processes involving the heart led to the search for additional diagnostic tools. Fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) has been proposed for its diagnostic abilities in several infectious diseases including cardiac infections. A literature review of studies evaluating FDG PET/CT in native valve infective endocarditis (IE), prosthetic valve IE, cardiac implantable electrical device (CIED) infection, and left ventricular assist device (LVAD) infection is presented, focusing on studies published in recent years. Overall, in prosthetic valve endocarditis (PVE), FDG PET/CT demonstrate high sensitivity (73-93%) and specificity (80-95%), while in native valve endocarditis (NVE) the sensitivity is very low (22-68%), with high specificity (97-100%) similar to PVE. For CIED, LVAD infection, and transcatheter aortic valve implantation associated endocarditis, data come from small studies and show good diagnostic performance of FDG PET/CT. International guidelines are increasingly recommending FDG PET/CT for the diagnosis of specific conditions of cardiac infections. Beyond the diagnostic performance ability, few studies have evaluated the added benefit of FDG PET/CT in terms of clinical outcomes of patients with suspected cardiac infection. This should be the focus in future studies.

Mitral Valve Infective Endocarditis after Trans-Catheter Aortic Valve Implantation

Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.

Cardiac Imaging for Diagnosis and Management of Infective Endocarditis

Imaging is central to the care of patients with infective endocarditis. While transthoracic and transesophageal echocardiography are the principle imaging techniques, additional modalities including positron emission tomography and cardiac computed tomography, and to a lesser extent intracardiac echocardiography, play an increasing role. This review discusses the role of cardiac imaging in establishing the diagnosis of endocarditis, in predicting its embolic risk and in making decisions regarding the need for and timing of surgery.

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.

Surgical treatment of valve endocarditis in high-risk patients and predictors of long-term outcomes

Infective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97-100%), 96% (95% CI 92-100%), 85.9% (95% CI 76-97%), and 74% (95% CI 60-91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

Infective Endocarditis Caused by Staphylococcus Aureus after Transcatheter Aortic Valve Replacement

BACKGROUND

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

METHODS

Data was obtained from the Infectious Endocarditis after TAVR International Registry including patients with definite IE following TAVR from 59 centers in 11 countries. Patients were divided into two groups according to microbiological etiology (non-S aureus-IE, non-SA-IE vs. S aureus-IE, SA-IE).

RESULTS

SA-IE was identified in 141 out of 573 (24.6%) patients, methicillin-sensitive S aureus in most cases (115/141, 81.6%). SEV were more common than BEV in patients with early SA-IE. Major bleeding and sepsis complicating TAVR, neurological 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 IE post-TAVR patients, 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 mortality (71.5% vs. 49.6%, p<0.001) rates were higher among SA-IE (vs. non-SA-IE) patients. Surgery at the time of index SA-IE was associated with a lower mortality rate at follow-up (HR_adj: 0.46, 95% CI: 0.22-0.96, p=0.038).

CONCLUSIONS

SA-IE represented ∼ 25% of IE cases after TAVR and was associated with a 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.

Medical malpractice in aortic valve and mitral valve replacement surgery in North America

BACKGROUND

Aortic and mitral valve replacement are commonly performed by cardiovascular surgeons, but little data quantitatively analyzes the etiology and prevalence of medical malpractice litigations involving these operations. This study aims to analyze incidence, cause, and resolution of medical malpractice lawsuits involving aortic and mitral valve replacements, alone and in combination with coronary artery bypass and/or aortic procedures.

METHODS

The Westlaw legal database was utilized to compile relevant litigations across the United States from 1994-2019. Clinical data, verdict data, demographic data, and litigation attributes were compiled. Fisher-exact tests and Mann-Whitney tests were performed for statistical analyses.

RESULTS

One hundred four malpractice litigations involving aortic valve replacement and 55 litigations involving mitral valve replacement were included in this analysis. The mean age of patients was 55.2 years and proportion of female patients was 32.7% in aortic valve replacements litigations, compared to a mean age of 54.1 years and female patients in 61.8% of mitral valve replacements litigations. Significant relationships exist between an alleged failure to monitor the patient and defendant verdicts (p=0.01), delayed treatment and defendant verdicts (p=0.04), and incidence of infective endocarditis and plaintiff verdicts (p=0.04) in aortic valve replacement litigations. Similarly, significant relationships exist between an alleged failure to diagnose and settlement verdicts (p=0.047), and stroke incidence and defendant verdicts (p=0.03) in mitral valve replacement litigations.

CONCLUSIONS

In addition to excellent surgeon patient/family communication, administering surgical treatment in a timely manner, diagnosing and acting on concomitant medical conditions, and close patient monitoring may diminish medical malpractice litigation involving aortic and mitral valve replacement operations.

Incidence and outcomes of infective endocarditis following transcatheter aortic valve implantation

INTRODUCTION

Prosthetic valve infective endocarditis is a feared and potentially catastrophic complication of valvular intervention. Transcatheter aortic valve implantation has transformed the modern management of aortic stenosis and vastly altered the demographics of those patients undergoing valve replacement.

AREAS COVERED

As a relatively nascent development, what TAVI means for the epidemiology of infective endocarditis, how to identify those patients undergoing the procedure at greatest risk, and how best to prevent and manage the condition remains the subject of fervent research activity. In this review, we appraise relevant contemporary data discussing the incidence, microbiological profiles, associated risk factors and clinical outcomes of infective endocarditis after TAVI.

EXPERT OPINION

Present outcomes are poor, with exceedingly high in-hospital and long-term mortality. Evidence to support surgical management in this patient group is lacking. Prevention is therefore paramount and a logical focus for future research attention.

A technique to resect the Edwards SAPIEN 3 Transcatheter Heart Valve 18 months after implantation in case of surgical aortic valve replacement

Transcatheter aortic valve implantation (TAVI) evolved to an established treatment for meanwhile moderate-risk surgical patients suffering from severe aortic stenosis. Due to its less invasiveness, avoiding the use of cardiopulmonary bypass, the procedure demonstrated to be an efficient and safe treatment option. However, long-term results regarding these new valve prostheses are still lacking. Potential prosthesis failure and/ or dysfunction would require either, if feasible, a transcatheter "valve in valve" procedure, or a conventional surgical valve replacement. In the literature, anecdotal reports are describing surgical removal techniques of the currently transcatheter-implanted prostheses. We herein propose a modified surgical removal technique of an infected Edwards SAPIEN 3 Transcatheter Heart Valve 18 months after its implantation.

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.