18F-Fluorodeoxyglucose Uptake Pattern in Noninfected Transcatheter Aortic Valves

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.

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: 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.

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.

Safety and efficacy of repeat transcatheter aortic valve replacement for the treatment of transcatheter prosthesis dysfunction

Introduction: Transcatheter aortic valve replacement (TAVR) has recently expanded toward the treatment of younger patients with lower surgical risk and longer life expectancy. Thus, transcatheter heart valve (THV) durability has become a central issue, and an important increase in the number of TAVR-in-TAVR is expected in the coming years. Areas covered: Overview of the current status of TAVR-in-TAVR for the treatment of THV dysfunction, focusing on safety and efficacy of repeat TAVR procedures. Expert opinion: An accurate analysis of the pre-procedure cardiac computed tomography, incorporating new parameters such as the position of the top of the first THV in relation to the sinotubular-junction, will be necessary to assess the risk of coronary occlusion. Subsequent coronary angiography will be necessary in a proportion of TAVR-in-TAVR patients, but coronary access may be very difficult or even impossible in some of them. Therefore, the choice between TAVR and SAVR in young low-risk patients should incorporate the potential need for treating coronary events at mid- to long-term follow-up. Likewise, the choice of the valve type and the implantation position at the time of the first TAVR procedure should take into account the possibility of TAVR-in-TAVR in the future.Abbreviations ACS: acute coronary syndrome; CO: coronary obstruction; EOA: effective orifice area; SAVR: surgical aortic valve replacement; SVD: structural valve degenerationTAVR: transcatheter aortic valve replacement; THV: transcatheter heart valve.