Data from this large international registry associate endocarditis after a transcatheter aortic valve replacement (TAVR) with high rates of early and late mortality, and might help find predictors identifying patients with the highest risk of developing this rare but dangerous complication.
So far, information on endocarditis after TAVR was limited to small populations. In consequence, this is by far the largest study on the subject matter, featuring very strict inclusion criteria (only patients presenting definitive endocarditis according to Duke criteria were analyzed).
The incidence of endocarditis is 1.1% per patient-year in a population of 20,006 patients undergoing TAVR in 47 centers in Europe, North America, and South America between June 2005 and October 2015.
Mean time from the procedure to a diagnosis of endocarditis was 5.3 years, and the condition was related to another in-hospital infection in over half the patients.
After making adjustments to account for various possible confounding variables, men (hazard ratio [HR]: 1.69; 95% confidence interval [CI]: 1.13 to 2.52), diabetic patients (HR: 1.52; 95% CI: 1.02 to 2.29), and patients with moderate to severe paravalvular aortic insufficiency (HR: 2.05; 95% CI: 1.28 to 3.28) presented the highest risk of infective endocarditis.
Enterococci species (24.6%) and Staphylococcus aureus (23.3%) were the most frequently isolated microorganisms in cultures.
Of 250 cases of definitive endocarditis diagnosed, only 14.8% underwent surgery and 36% died during hospitalization. At 2 years, two-thirds of those patients had died.
Conclusion
Male sex, diabetes, and residual paravalvular insufficiency are significantly associated with infective endocarditis in patients undergoing transcatheter aortic valve replacement. Patients with endocarditis present a high mortality rate.
Editorial
Given the poor prognosis for conventional treatment and the extremely high surgical risk in these cases, treatment decisions for patients with endocarditis after TAVR must be taken as a team, on a case-by-case basis.
Prevention seems to be the best weapon against endocarditis; there are no specific recommendations on percutaneous valves, much less in the presence of risk factors, such as moderate to severe paravalvular insufficiency, which double the risk.
Original title: Association between transcatheter aortic valve replacement and subsequent infective endocarditis and in-hospital death.
Reference: Regueiro A et al. JAMA. 2016;316:1083-1092.
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