High Mortality Following Infective Endocarditis After TAVR Warrants Better Prevention, Treatment

The possibility of a patient developing infective endocarditis (IE) after transfemoral TAVR, while slim, warrants early and aggressive therapy say researchers who have published what they believe is the largest, single-center study looking at predictors and outcomes in this group.

Newer iterations of approved and investigational transcatheter valves continue to emerge along with more and more studies supporting their use, yet much remains unknown in terms of rare complications, including the risk of lethal infections.

Researchers led by Norman Mangner, MD (University of Leipzig, Germany), looked at the 3.02% (n = 55) of transfemoral TAVR patients who developed IE after being treated at their institution between February 2006 and September 2014. Their retrospective findings appear in a research letter appearing online ahead of print in the June 21, 2016 issue of the Journal of the American College of Cardiology.

About three-quarters of patients in the series developed the infection within a median of 35 days and it was considered “definitive” in 36.4% and “probable” in 63.6% of subjects.

Diagnosis of IE was linked with higher rates of residual aortic regurgitation ≥ grade 2, mean pressure gradient, VARC-defined strokes, and renal failure at 30 days post-TAVR. Additionally, in multivariate analysis, chronic hemodialysis (HR 8.37; 95% CI 2.54-27.63) and peripheral artery disease (HR 3.77; 95% CI 1.88-7.58) were found to be independent predictors of developing IE.

Almost two-thirds of IE patients died in the hospital with a median survival of 28 days—chronic hemodialysis, heart failure, and sepsis/shock were all independent predictors of mortality on multivariate analysis. One-year mortality was 74.5%.

More than three-quarters of cases were linked with bacteremia and 42% were classified as nosocomial/health care-acquired. Coagulase-positive staphylococci (38.2%), coagulase-negative staphylococci (9.1%), and streptococci (3.6%) were identified as the “typical” organisms responsible for IE.

Prevention, Better Management Needed

Mangner told TCTMD in an email that he was surprised by the “high incidence” of IE after TAVR. “Health care providers should be aware [of] this condition due to the . . . high rate of nosocomial/health care-related causes of IE” and that “patients on chronic hemodialysis and with peripheral artery disease were at the highest risk for developing IE,” he said.

It’s “too early” for specific recommendations in terms of care, Manger continued. However, physicians should be thinking about the make-up of perioperative antibiotic prophylaxis, how long temporary pacemaker leads are needed, how to improve hygiene around high-risk patients, and how to optimzie treatment for TAVR patients who do develop IE, he said.

Because of the retrospective nature of this single-center study, Alon Eisen, MD (Rabin Medical Center, Petah Tikva, Israel), who was not involved in the study, told TCTMD in an email that the results “should be interpreted with caution.” Nevertheless, the findings add “to the little literature that is available,” he said.

Eisen encouraged interventional cardiologists to educate themselves about IE and called for more thorough inspection of febrile states in patients after TAVR, when appropriate. “This report and prior studies highlight the need to examine, in future trials, preventive measures such as better asepsis and antibiotic prophylaxis, diagnostic strategies, risk factors, and management of IE after TAVR,” he said. “Importantly, the poor results obtained with a more conservative strategy in the majority of patients, even in the presence of a complication with an indication for surgery, highlight the need to examine a more invasive approach for these high-risk cases.”

Until that can happen, Eisen stressed that a “careful case-by-case management by the heart team remains the cornerstone.” 

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