Post-TAVR Infection Reported in 1 of 5 Patients But Not Linked with Mortality

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In-hospital infections occur in about 20% of patients who undergo transcatheter aortic valve replacement (TAVR), according to a study published online April 8, 2013, ahead of print in the American Journal of Cardiology. Although not all infections are necessarily procedure-related, the research suggests that improvements in patient care before and after TAVR may reduce these complications.

Peter P.T. de Jaegere, MD, PhD, of Erasmus Medical Center (Rotterdam, The Netherlands), and colleagues enrolled 298 consecutive patients from 2 centers in The Netherlands (n = 230) and Colombia (n = 68) who underwent TAVR with the CoreValve device (Medtronic, Minneapolis, MN) from November 2005 to November 2011.

Infection Fairly Common

Overall, 58 patients (19.5%) experienced in-hospital infections, of which 43.1% were urinary tract infections, 20.7% pneumonia, 20.7% of undetermined origin, and 12.1% access site infections. Two patients had multiple infection sites.

Multivariate analysis showed that independent predictors of infection after TAVR were surgical access of the femoral artery (adjusted OR 4.18; 95% CI 2.02-17.19), major stroke (adjusted OR 3.21; 95% CI 1.01-9.52), and BMI greater than 25 kg/m² (adjusted OR 2.27; 95% CI 1.12-4.59).

However, infection did not predict mortality, either at 30 days (adjusted OR 1.27; 95% CI 0.49-3.30) or 1 year (adjusted HR 1.24; 95% CI 0.68-2.25).

Patients with infections had lower preprocedure hemoglobin levels (P = 0.03) and longer procedures (P = 0.023), but there was no difference in baseline leukocyte count between the groups. Additionally, patients with infections had longer median hospital stays compared with those without infections (15 vs. 7 days; P < 0.0001).

Outpatient Procedures Preferable

In a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said he was unsurprised at the “relatively high frequency of infections,” because “these patients are so elderly and otherwise sick.” Interestingly, the infections occur soon after TAVR, he noted, suggesting that the majority of patients are not having outpatient procedures.

Stephen G. Ellis, MD, of the Cleveland Clinic (Cleveland, OH), told TCTMD in a telephone interview that his institution does not perform TAVR with surgical cutdowns, resulting in “better luck in terms of access site infections.”

Dr. Ellis said the study results are predictable, apart from the fact that infection did not track with long-term outcomes. However, since the population was small, “to say that [infection] doesn’t predict mortality is a little bit of a stretch,” he cautioned, pointing out that “if you look at the survival curves, the infected patients track downward for 3 months or so and then seem to stabilize. So there may be a bit of a signal here if they looked at larger numbers of patients.”

Preventative Methods

Acknowledging that not all infections are preventable, Dr. Kirtane said the priorities need to center around “trying to get these patients out of the hospital as quick as possible and driving toward percutaneous access.” Additionally, “it would be nice if you could ‘tune-up’ patients before they have the procedure so that these comorbidities and [other potential problems] don’t ultimately get to manifest themselves,” he suggested.

With urinary tract infections found to be the most common type of infection after TAVR, Dr. Ellis said that “maybe part of the message here is to get that Foley out as soon as possible.” Also, the use of general anesthesia “is kind of a set-up for pneumonia,” he said.

Moving forward, “it would be useful to see a report from another group to see if the infection rate was comparable, to see if this is sort of a global problem or not, and then to look at differences in patient management,” Dr. Ellis advised, suggesting that another area of study should be infection after transapical TAVR, which “if anything . . . would be worse” than after transfemoral access.

Study Details

One hour before and upon completion of TAVR, prophylactic antibiotic therapy was administered according to local practice guidelines (cefazolin 1 g at both times). If needed, antibiotic therapy was continued postprocedurally. Patients underwent transfemoral (n = 287), subclavian (n = 9), or transapical TAVR (n = 2) under general anesthesia or deep sedation.

 

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Source:
van der Boon RMA, Nuis R-J, Benitez LM, et al. Frequency, determinants and prognostic implications of infectious complications after transcatheter aortic valve implantation. Am J Cardiol. 2013;Epub ahead of print.

 

 

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