番茄社区

Several risk factors for infective endocarditis after transcatheter aortic valve replacement (TAVR) were identified in a retrospective study.

Overall, , of Quebec Heart & Lung Institute in Canada, and colleagues found a 1.1% rate of infective endocarditis per person-year. It took a median of 5.3 months for endocarditis to develop after TAVR, according to their study appearing online in the .

"The rate of infective endocarditis after TAVR observed in the present study is similar to that reported for surgical prosthetic valve endocarditis," they concluded, noting that the less-invasive nature of TAVR did not seem to reduce the likelihood of infection.

Upon hospitalization for endocarditis, in-hospital mortality occurred in 36%. The 2-year mortality rate was 66.7%.

Seemingly more susceptible to infective endocarditis were:

• Younger patients: 78.9 years versus 81.8 years (HR 0.97 per year, 95% CI 0.94 to 0.99)
• Men: 62% versus 49.7% for women (HR 1.69, 95% CI 1.13 to 2.52)
• Patients with diabetes mellitus: 41.7% versus 30% for non-diabetic cohort (HR 1.52, 95% CI 1.02 to 2.29)
• Those with moderate-to-severe aortic regurgitation: 22.4% versus 14.7% for less severe (HR 2.05, 95% CI 1.28 to 3.28)

However, the link between younger age and infective endocarditis may not be what it seems, said , of Tel Aviv University in Israel. "Younger patients who undergo TAVR usually have other high-risk features."

Due to the retrospective nature of Rodés-Cabau's investigation, the finding may have been confounded by advanced disease and related comorbidities, suggested Eisen, who was not involved in the research.

Nevertheless, the study "should alert clinicians to the higher than expected frequency of TAVR-associated endocarditis," said , of New York-Presbyterian Hospital/Columbia University in New York City, who was not involved in the study. "We often think of TAVR as approaching no risk for surgical-type complications, but this study shows that endocarditis is certainly possible after TAVR."

"Moreover, the consequences are often more damaging than surgery, as [removing the implant] is generally the only way to clear many types of these infections, and that may be too high risk in many of these patients," George told 番茄社区.

"TAVR procedures -- by virtue of a fabric skirt on the valve, multiple pieces of hardware in the delivery system, access routes in the groin which is generally an unclean area, and many exchanges during a case -- lend themselves to a higher risk for endocarditis," he added. "Thus absolute precaution must be made during the procedure."

The study by Rodés-Cabau's group took data from the retrospective Infectious Endocarditis after TAVR International Registry. Patients (n=20,006) came from 47 centers and were enrolled from 2005 to 2015.

Associated with death after an episode of infective endocarditis were:

• A higher logistic EuroSCORE: 23.1% versus 18.6% (OR 1.03 per 1% increase, 95% CI 1.00 to 1.05)
• Heart failure: 59.3% versus 23.7% (OR 3.36, 95% CI 1.74 to 6.45)
• Acute kidney injury: 67.4% versus 31.6% (OR 2.70, 95% CI 1.42 to 5.11)

More than half of cases were associated with healthcare (52.8%). The most common species encountered were Enterococci (24.6%) and Staphylococcus aureus (23.3%).

Eisen emphasized that the definition of healthcare-related infective endocarditis was broad -- it included residence in nursing homes or long-term care facilities, which is "quite common in the elderly population," he said.

Even so, the pattern "reinforces the principle to bring people electively on the day of the procedure, and to discharge as soon as medically stable," according to George. "To keep patients in house for non-medical reasons can have grave infectious consequences."

"Another aspect that may be overlooked is the state of a patients dentition," George said. "This often worsens significantly in the elderly. Dental examinations must be routine, and an informed decision must be made whether to go for dental work before or after an intervention."

"Guidelines for postop dental care timing are unclear, but 3-6 months is probably sufficient for endothelialization of any fabric on a valve," he said.

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