Cardiac Surgery Compared With Antibiotics Only in Patients Developing Infective Endocarditis After Transcatheter Aortic Valve Replacement

Abstract

BackgroundInfective endocarditis (IE) after transcatheter aortic valve replacement is a devastating complication associated with a high mortality. Our objective was to determine the impact of cardiac surgery (CS) and antibiotics (IE‐CS) compared with medical treatment with antibiotics only (IE‐ABx) on 1‐year mortality in patients developing IE after transcatheter aortic valve replacement.Methods and ResultsPatients developing IE after transcatheter aortic valve replacement were included in this retrospective analysis. All‐cause 1‐year mortality was the primary end point. A total of 20 patients underwent IE‐CS compared with 44 patients treated by IE‐ABx. In this unmatched cohort, patients treated by IE‐ABx were older (P=0.006), had a higher Society of Thoracic Surgeons score (P=0.029), and more often had severe chronic kidney disease (P=0.037). One‐year mortality was not different between groups (IE‐CS versus IE‐ABx, 65% versus 68.2%; P=0.802). The rate of any complication during treatment was higher in the IE‐CS group (P=0.024). In a matched cohort, baseline characteristics were not significantly different. All‐cause 1‐year mortality was not different between groups (IE‐CS versus IE‐ABx, 65% versus 75%; P=0.490). A Cox regression analysis revealed any indication for surgery (hazard ratio, 6.20; 95% confidence interval, 1.80–21.41; P=0.004), sepsis on admission (hazard ratio, 4.03; 95% confidence interval, 1.97–8.24; P<0.001), and mitral regurgitation ≥2 (hazard ratio, 2.91; 95% confidence interval, 1.33–6.37) as factors associated with 1‐year mortality.ConclusionsIn patients developing IE after transcatheter aortic valve replacement, mortality was predicted by the severity of IE and concomitant mitral regurgitation. In this small, and therefore statistically limited, but high‐risk patient cohort, CS provided no significant mortality benefit compared with medical therapy. Individual decision making by a “heart and endocarditis team” is necessary to offer those patients the most reasonable treatment option.

Infective Endocarditis After Transcatheter Aortic Valve Replacement: The Worst That Can Happen

“…Contrary to their previous paper, in which 31.9% patients with TAVR‐IE had negative imaging studies,2 the authors included in the current study5 only patients with echocardiographic evidence of IE. Forty‐one patients with definite or possible TAVR‐IE were thus excluded from the study because of the absence of echocardiographic evidence of IE 5.…”

“…The current article from Mangner et al5 adds new information on the role of surgery in patients with TAVR‐IE. In their series of 64 patients with TAVR‐IE, 20 were treated by surgery.…”

“…Forty‐one patients with definite or possible TAVR‐IE were thus excluded from the study because of the absence of echocardiographic evidence of IE 5. As recognized by the authors, although they used the ESC guidelines definition of “definite or possible IE,”13 some patients did not undergo imaging techniques other than echocardiography and may represent false‐negative echocardiographic studies but in fact have true IE.…”

“…Pending the results of future studies, we should recognize that factors other than surgery mainly influence outcome in patients with TAVR‐IE, including comorbidity, frailty, heart failure, renal failure,4 and, in the current paper,5 disease characteristics (eg, sepsis on admission or a formal indication for cardiac surgery). We do not currently have enough published data to conclude that surgery is or is not better than medical therapy alone in patients with TAVR‐IE.…”

“…In this issue of the Journal of the American Heart Association (JAHA) , Mangner et al5 tried to determine the impact of cardiac surgery compared with medical treatment on the prognosis of patients developing IE after TAVR.…”