Original title: Incidence and clinical impact of infective endocarditis after transcatheter aortic valve implantation. Reference: Manuel Martínez-Sellés et al. EuroIntervention 2015;10-online publish-ahead-of-print February 2015.
Prosthesis endocarditis is a complication with serious clinical consequences due to its high morbimortality. Infective endocarditis (IE) in TAVI has been described in few cases and, in cohort studies, it occurs within 0 to 2.3% after one to three years follow up.
The aim of this study was to describe the characteristics of IE after TAVI implantation. It used the Spanish database GAMES (Grupo de Apoyo al Manejo de la EndocarditiS, support group for endocarditis management), a prospective registry of consecutive IE patients in 26 hospitals. From 739 IE cases diagnosed during the study, 1.3 were post TAVI, and these 10 cases, contributed by five centers, represented 1.1% of the 952 TAVI procedures performed during that period. Population mean age was 80 ys.
All valves were implanted transfemorally. IE appeared a median of 139 days post implantation. Mean age adjusted Charlson comorbidity index was 5.45. Chronic kidney disease was frequent (5 patients), as were atrial fibrillation (5 patients), chronic obstructive pulmonary disease (4 patients), and ischemic heart disease (4 patients). Six patients presented IE on the aortic valve, and four on the mitral valve; this last group had a higher percentage of mitral prosthesis (2 patients). Vegetations were found in 7 cases and 4 presented embolism. Only 1 patient underwent surgery to treat IE. Five patients died during follow up, 2 of them during the admission in which the valve was implanted.
Nine of the ten patients with IE received a CoreValve and the Edwards SPAIEN was used in 1/3 of patients from the whole database, which is not enough data to determine whether a valve is more prone to IE than the other. Six patients presented hospital IE or IE related to invasive techniques (urinary/endovascular catheterization).
Conclusion
IE is a low frequency complication but serious after TAVI: it affects around 1% of patients and translates into a relatively high mortality rate. IE appeared during the first year in 9 patients out of 10 in this series.
Editorial Comment
TAVI implantation is used mainly for elderly patients with frequent comorbidities, and IE means the worst prognosis. On the other hand, many TAVI patients are inoperable, which limits the options to treat IE.
IE prevalence in TAVI patients is similar to that of surgical patients; in the PARTNER study, IE incidence in cohort B at two years was similar in both groups (1.5% TAVI vs. 1.0% surgery). Also 1 year mortality was similar in both groups.
Performing this procedure in the cath lab, not in the hybrid operating room, may be a possible risk factor, as well as touching the anterior leaflet of the mitral valve (for IE on the mitral valve, the infected prosthesis can touch the anterior leaflet of the mitral valve, facilitating IE), paravalvular leak, advanced age and comorbidities. Patients should be monitored closer during the first year, with a low doubt threshold for IE and maximize care during invasive procedures.
Courtesy of Dr. Ignacio Batista and Dr. Ariel Duran.
Montevideo, Uruguay
Dr. Ignacio Batista y Dr. Ariel Duran.