Fever After TAVR Common, but Antibiotics Rarely Needed

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Nearly half of patients undergoing transcatheter aortic valve replacement (TAVR) have short febrile episodes after the procedure, but documented bacterial infections and complications are rare. In a study published online December 26, 2013, ahead of print in the American Journal of Cardiology, researchers suggest that a ‘watchful waiting’ strategy may be prudent in many of these cases rather than initiation of broad-spectrum antibiotics.

Eran Leshem-Rubinow, MD, MHA, of Tel-Aviv Medical Center (Tel-Aviv, Israel), and colleagues looked at 140 consecutive patients enrolled in the Tel-Aviv Angiography Prospective Study (TAPAS) who underwent transfemoral TAVR at their institution between March 2009 and June 2012. Prior to the procedure, all patients received antibiotic prophylaxis with a first- or second-generation cephalosporin or vancomycin. The majority of patients (n = 137) received the CoreValve prosthesis (Medtronic, Minneapolis, MN), while only 3 patients received the Edwards Sapien valve (Edwards Lifesciences, Irvine, CA).

Some Fever in Nearly Half

Within 7 days postprocedure, 66 patients (47%) experienced a fever of at least 99.5 degrees F, with 27 (19.4%) having fever of at least 100.0 degrees F. Of these 27 febrile patients, 11 (40.7%) had at least 2 documented temperature spikes and fever lasting longer than 8 hours. Baseline characteristics were similar between those with and without fever ≥ 100.0 degrees, and no preprocedural clinical predictors of fever were identified.

Most febrile episodes (74%) occurred in the first 48 hours. A broad-spectrum antibiotic was given in 81.5% (n = 22) of febrile patients and all cases when fever was prolonged (>8 hours).  Infections were documented in 5 febrile patients. Of these, 2 had bacteremia infections with prolonged and high-grade fever (≥ 100 degrees), and both pathogens isolated (Enterococcus faecalis and Klebsiella pneumoniae) were resistant to standard prophylaxis. Urinary pathogens were isolated from the other 3 patients (none with an indwelling catheter), only 1 of whom had prolonged fever. These isolates were mostly resistant to the prophylactic antibiotics used.

Primary outcome analysis, combining all post-TAVR febrile episodes (short and prolonged duration), found that the occurrence of fever was not associated with increased 30-day mortality or combined outcome score (VARC-2). Among other safety outcomes assessed, only early postprocedural stroke and pericardial tamponade were associated with a febrile event of any duration. Additionally, functional outcomes at 30 days were similar regardless of fever (table 1).

 Table 1. Safety, Functional Outcomes

 
However, compared with a single febrile spike or no fever, prolonged fever (>8 hours, n=11) was associated with an increased 30-day mortality rate (OR 7.55; 95% CI 2.4-24.2) and a doubling of hospitalization time (mean 14.3 days vs. 7.3 days; P = 0.04).

‘Watchful Waiting’ Strategy Advocated

Dr. Leshem-Rubinow and colleagues say that prior evidence supports an association between postprocedural complications and noninfectious inflammatory response. Specifically, data on patients undergoing endovascular repair of abdominal aortic aneurysms demonstrate similar occurrence of fever, referred to in the literature as “postimplantation syndrome.” The results of their study, they add, suggest that a watchful waiting strategy is acceptable after the first occurrence of fever of at least 100 degrees in an otherwise stable patient.

“If the fever recurs or does not subside, the patient should be re-examined in search for a possible source of fever, and undergo a workup which includes a complete blood count, blood chemistry and inflammatory markers, as well as blood and urine cultures and a chest X-ray,” they write. “These should be followed by a consultation with an infectious disease specialist and antibiotic therapy initiation.” If antibiotics are warranted, the study authors conclude, “the chosen antibiotic should cover bacteria resistant to local prophylactic regimens.”

 

Source:
Leshem-Rubinow E, Amit S, Steinvil A, et al. Frequency, pattern and cause of fever following transfemoral transcatheter aortic valve implantation. Am J Cardiol. 2013;Epub ahead of print.

 

 

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