Very early infective endocarditis after transcatheter aortic valve replacement

Bacteraemia after transcatheter aortic valve implantation: a nationwide cohort study

BACKGROUND

Bacteraemia and infective endocarditis (IE) are rare but severe complications of transcatheter aortic valve implantation (TAVI). Limited data exist on the incidence and microbiological profile of early bacteraemia in this population. This study aimed to evaluate the 6-month incidence of bacteraemia, IE and associated mortality following TAVI.

METHODS

Using Danish nationwide registries, all patients who underwent TAVI from 2012 to 2021 were identified and matched 1:1 by age, sex and index year with patients who underwent elective coronary angiography (CAG). Outcomes were assessed with cumulative incidence functions and adjusted HRs.

RESULTS

Among 5990 patients with first-time TAVI (57% male, mean age 80 years, SD 6.9), bacteraemia occurred in 4.2% within 6 months, compared with 2.6% in the CAG group (adjusted HR 1.57, 95% CI 1.26 to 1.96). Common pathogens post-TAVI included Streptococci (20%), Coagulase-negative staphylococci (19%) and Enterococci (18%), differing from the CAG group, where Coagulase-negative staphylococci (22%) and Staphylococcus aureus (16%) predominated. IE developed in 1.1% of patients with TAVI versus 0.1% of patients with CAG (adjusted HR 20.01, 95% CI 5.97 to 67.48).

CONCLUSION

Bacteraemia and IE rates are substantially elevated within 6 months following TAVI compared with elective CAG. The bacterial profile post-TAVI suggests that current prophylactic antibiotic regimens may not provide adequate coverage.

Comparison between Duke, European Society of Cardiology 2015, International Society for Cardiovascular Infectious Diseases 2023, and European Society of Cardiology 2023 criteria for the diagnosis of transcatheter aortic valve replacement-related infective endocarditis

AIMS

Transcatheter aortic valve replacement-related infective endocarditis (TAVR-IE) is associated with a poor prognosis. TAVR-IE diagnosis is challenging, and benefits of the most recent classifications [European Society of Cardiology (ESC)-2015, International Society for Cardiovascular Infectious Diseases (ISCVID)-2023, and ESC-2023] have not been compared with the conventional Duke criteria on this population. The primary objective was to compare the diagnostic value of the Duke, ESC-2015, ISCVID-2023, and ESC-2023 criteria for the diagnosis of TAVR-IE. The secondary objectives were to determine which criteria increase the diagnostic accuracy of each classification and to evaluate in-hospital and 1-year mortality of TAVR-IE.

METHODS AND RESULTS

From January 2015 to May 2022, 92 patients with suspected TAVR-IE were retrospectively included in two French centres, including 82 patients with definite TAVR-IE and 10 patients with rejected TAVR-IE as defined by expert consensus. Duke classification yielded a sensitivity of 65% [95% confidence interval (CI): 53-75%] and a specificity of 100% (95% CI: 69-100%) for the diagnosis of TAVR-IE. ESC-2015 classification increased Duke criterion sensitivity from 65 to 73% (P = 0.016) but decreased specificity from 100 to 90%. ISCVID-2023 and ESC-2023 also increased Duke criterion sensitivity from 65 to 76% (P = 0.004) and 77% (P = 0.002), respectively, but also decreased specificity from 100 to 90%. A positive 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was the most helpful criterion, as 10 patients (11%) were correctly reclassified. In-hospital mortality after TAVR-IE was 21% and 1-year mortality was 38%.

CONCLUSION

A multimodality imaging approach, including 18F-FDG PET/CT and gated cardiac CT, is the cornerstone of TAVR-IE diagnosis and explains the higher sensitivity of ESC-2015 and recent classifications compared with Duke criteria.

Evaluation of systemic inflammatory response following transcatheter aortic valve replacement: a pathway to rational antibiotic use

PURPOSE

Elevations in inflammatory markers after transcatheter aortic valve replacement (TAVR) often lead to preemptive antibiotic therapy (ABT). Distinguishing between physiological inflammatory reaction and true infection is crucial for rational ABT use.

METHODS

This retrospective study included 1275 consecutive TAVR patients from January 2020 to July 2022. Infectious foci, ABT administration, and inflammatory markers over seven days post-procedure were evaluated. Using multivariable logistic regression, predictors for infection were identified and integrated into the Risk of Infection After TAVR (RIAT) score.

RESULTS

An infectious focus was retrospectively identified in 2.6% of patients, while 11.4% received ABT. Distinct trends in body temperature (BT), white blood cells (WBC), and C-reactive protein (CRP) were noted, with BT and WBC peaking on day 1 and CRP on day 3. Significant predictors of infection included a rise in BT of ≥ 0.2 °C between day 1 and 3 (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.38-6.88, p = 0.006), elevated WBC counts ≥ 12 × 109/L (OR 3.77, 95% CI 1.67-8.48, p = 0.001), and CRP levels ≥ 80 mg/L (OR 5.72, 95% CI 2.59-12.64, p < 0.001) within three days after TAVR. Integrating these into the RIAT score revealed an infection probability of 1.5% for scores 0-3 points, 9.2% for scores 4-6 points, and 54.5% for scores 7-8 points.

CONCLUSION

Our findings indicate significant ABT overuse among TAVR recipients, likely due to misinterpretation of postoperative physiological reactions. Incorporating specific changes and thresholds of BT, WBC, and CRP post-TAVR into the RIAT score improved risk prediction for infection, underscoring its utility in enhancing antibiotic stewardship in this growing patient population.

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.

Infective Endocarditis After Transcatheter Versus Surgical Aortic Valve Replacement

BACKGROUND

Scarce data are available comparing infective endocarditis (IE) following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study aimed to compare the clinical presentation, microbiological profile, management, and outcomes of IE after SAVR versus TAVR.

METHODS

Data were collected from the "Infectious Endocarditis after TAVR International" (enrollment from 2005 to 2020) and the "International Collaboration on Endocarditis" (enrollment from 2000 to 2012) registries. Only patients with an IE affecting the aortic valve prosthesis were included. A 1:1 paired matching approach was used to compare patients with TAVR and SAVR.

RESULTS

A total of 1688 patients were included. Of them, 602 (35.7%) had a surgical bioprosthesis (SB), 666 (39.5%) a mechanical prosthesis, 70 (4.2%) a homograft, and 350 (20.7%) a transcatheter heart valve. In the SAVR versus TAVR matched population, the rate of new moderate or severe aortic regurgitation was higher in the SB group (43.4% vs 13.5%; P < .001), and fewer vegetations were diagnosed in the SB group (62.5% vs 82%; P < .001). Patients with an SB had a higher rate of perivalvular extension (47.9% vs 27%; P < .001) and Staphylococcus aureus was less common in this group (13.4% vs 22%; P = .033). Despite a higher rate of surgery in patients with SB (44.4% vs 27.3%; P < .001), 1-year mortality was similar (SB: 46.5%; TAVR: 44.8%; log-rank P = .697).

CONCLUSIONS

Clinical presentation, type of causative microorganism, and treatment differed between patients with an IE located on SB compared with TAVR. Despite these differences, both groups exhibited high and similar mortality at 1-year follow-up.

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 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.

Readmission with infective endocarditis within 90 days following transcatheter aortic valve implantation

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) continues to be the most common modality of treating aortic stenosis in the United States. While infective endocarditis (IE) and its outcomes have been well documented after surgical aortic valve replacement, the incidence and outcomes of early IE after TAVI have not been well described.

METHODS

All patients who underwent TAVI from 2012 through 2018 were identified using the National Readmission Database. Among them, patients who underwent TAVI at the index admission and readmitted within 90 days were included. Patients who died or had IE during the index admission were excluded. Clinical outcomes were compared between patients readmitted with IE (IE group) and those without (non-IE group).

RESULTS

A total of 168,283 patients were readmitted to a hospital within 90 days after TAVI. The median age of the IE group and non-IE group were 81 and 82 years old, respectively (p = 0.21). Of those, 525 (0.3%) were readmitted with IE. The median time from TAVI to readmission was 20 days. During readmissions, 11.6% of the IE group died while only 3.15% of the non-IE group experienced death (p < 0.001). The most common causative organism of IE was enterococcus (22.1%). Multivariable analysis revealed that congestive heart failure, cerebrovascular disease, dialysis, concomitant valve disease, Medicaid, and discharge to a facility were independently associated with readmission with IE within 90 days.

CONCLUSION

The incidence of readmission with IE is low after TAVI. However, the mortality was markedly high during readmissions. Surgical intervention was rarely performed for IE during the first admission. Enterococcus was the most common organism observed in IE after TAVI.

DISCLOSURE

IS receives institutional research support from Abbott, Atricure, cryolife, and Medtronic. None related to this manuscript.

CLINICAL TRIAL REGISTRATION

Not applicable.

Endocarditis in the intensive care unit: an update

PURPOSE OF REVIEW

The incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients with IE being admitted to intensive care units (ICU). Nearly half of patients with IE develop a complication during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE patients. This review discusses the contemporary perioperative and intensive care literature.

RECENT FINDINGS

IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of developing IE because they are often in a pro-inflammatory state and many also have several indwelling catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New developments in antibiotic treatment and adjunctive therapies are explored further in this review.

SUMMARY

The lack of evidence on ICU patients with IE highlights the critical importance of multidisciplinary decision-making and the need for further research.