Infective Endocarditis after Transcatheter Aortic Valve Replacement: Challenges in the Diagnosis and Management

Abstract

Although initially conceived for high-risk patients who are ineligible for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is now recommended in a wider spectrum of indications, including among young patients. However, similar to SAVR, TAVR is also associated with a risk of infectious complications, namely, prosthetic valve endocarditis (PVE). As the number of performed TAVR procedures increases, and despite the low incidence of PVE post-TAVR, clinicians should be familiar with its associated risk factors and clinical presentation. Whereas the diagnosis of native valve endocarditis can be achieved straightforwardly by applying the modified Duke criteria, the diagnosis of PVE is more challenging given its atypical symptoms, the lower sensitivity of the criteria involved, and the low diagnostic yield of conventional echocardiography. Delay in proper management can be associated with increased morbidity and mortality. Therefore, clinicians should have a high index of suspicion and initiate proper work-up according to the severity of the illness, the underlying host, and the local epidemiology of the causative organisms. The most common causative pathogens are Gram-positive bacteria such as Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., and Streptococcus spp. (particularly the viridans group), while less-likely causative pathogens include Gram-negative and fungal pathogens. The high prevalence of antimicrobial resistance complicates the choice of therapy. There remain controversies regarding the optimal management strategies including indications for surgical interventions. Surgical assessment is recommended early in the course of illness and surgical intervention should be considered in selected patients. As in other PVE, the duration of therapy depends on the isolated pathogen, the host, and the clinical response. Since TAVR is a relatively new procedure, the outcome of TAVR-PVE is yet to be fully understood.

Transcatheter Aortic Valve Replacement–Associated Prosthetic Valve Endocarditis Due to Pseudomonas aeruginosa

“…12 Since TAVR was first developed and reported in 2002, 13 there have been numerous studies reviewing TAVR-PVE but very few reported cases of TAVR-PVE due to P. aeruginosa. [2][3][4][5][6][7][8][9][10] The most common microorganisms causing TAVR-PVE have consistently been Enterococcus species, coagulase-negative Staphylococcus species, S. aureus, and Streptococcus species. Aerobic gram-negative bacilli causing TAVR-PVE are unusual, and P. aeruginosa endocarditis is rare.…”

“…The reported incidence of infective endocarditis after transcatheter aortic valve replacement (TAVR)/transcatheter aortic valve implantation (TAVI) ranges from 0.67% to 3.53% 1 . The most common microbes causing TAVR-associated prosthetic valve endocarditis (TAVR-PVE) are Enterococcus species, coagulase-negative Staphylococcus species, S. aureus , and streptococcal species 2–10 . Aerobic gram-negative bacilli are distinctly uncommon causes, and TAVR-PVE due to Pseudomonas aeruginosa is rare 1 .…”

“…1 The most common microbes causing TAVR-associated prosthetic valve endocarditis (TAVR-PVE) are Enterococcus species, coagulase-negative Staphylococcus species, S. aureus, and streptococcal species. [2][3][4][5][6][7][8][9][10] Aerobic gram-negative bacilli are distinctly uncommon causes, and TAVR-PVE due to Pseudomonas aeruginosa is rare. 1 We report the case of a patient with P. aeruginosa TAVR-PVE who originally developed P. aeruginosa bacteremia 18 days after the TAVR was deployed.…”

Catheter-Based Therapies: Current Practices and Considerations

“…This includes discussing the importance of regular dental care and antimicrobial prophylaxis before procedures that may lead to bacteremia. Recommended prophylaxis for penicillin tolerant and penicillin allergic patients included Amoxicillin and Clindamycin, respectively [62].…”

Endocarditis after Transcatheter Aortic Valve Replacement

“…Given the insidious presentation of prosthetic valves IE, it is worth mentioning that the high incidence of TAVR-IE after ViV-TAVR may also be attributed to unrecognized IE as the original cause of valve dysfunction. Conversely, post-TAVR moderate-severe aortic regurgitation is associated with a 2-fold increased risk of TAVR-IE [11], which is likely the consequence of high sheer stress from turbulent blood flow favoring the deposition of fibrin and the creation of a nidus for infection [25].…”