Prosthetic Valve Endocarditis After TAVR and SAVR

Abstract

Background: Prosthetic valve endocarditis (PVE) is a rare but critical mechanism of valve failure and death after transcatheter and surgical aortic valve replacement (TAVR, SAVR) warranting further analysis in modern aortic valve replacement experience. We characterize the incidence, risk factors, microbiological profile and outcomes of PVE from the PARTNER trials and registries (Placement of Aortic Transcatheter Valve). Methods: We analyzed a pooled cohort of all patients in PARTNER 1 and PARTNER 2 trials and registries. Patients had severe aortic stenosis, were treated with TAVR or SAVR, and were analyzed with respect to development of PVE. PVE adjudication by a clinical events committee was based on modified Duke Criteria. The incidence, infection timing, organism, and association between PVE and all-cause mortality were analyzed. Results: 8530 patients were included. PVE occurred in 107 cases (5.06 PVE events per 1000 person-years over a mean follow-up of 2.69±1.55 years [95% CI, 4.19–6.12]). The incidence of TAVR-PVE (5.21 PVE per 1000 person-years [95% CI, 4.26–6.38]) was not significantly different from SAVR-PVE (4.10 per 1000 person-years [95% CI, 2.33–7.22]; incident rate ratio, 1.27 [95% CI, 0.70–2.32]; P =0.44). Temporal risk of PVE was similar for TAVR and SAVR, even after adjusting for competing risk of death (hazard ratio, 1.15 [95% CI, 0.58–2.28]; P =0.69). Through multivariable analysis, PVE was associated with baseline cirrhosis (incident rate ratio, 2.86 [95% CI, 1.33–6.16]; P =0.007), pulmonary disease (incident rate ratio, 1.70 [95% CI, 1.16–2.48]; P =0.006), and renal insufficiency (incident rate ratio, 1.71 [95% CI, 1.03–2.83]; P =0.04). Timing of PVE was similar between TAVR and SAVR (<30 days: 4.2% vs 8.3%; 31 days to 1 year: 52.6% vs 66.7%; >1 year: 43.2% vs 25.0%; P =0.28). Staphylococcus occurred more commonly after SAVR (58.3% vs 28.4% in TAVR; P =0.04). PVE was strongly associated with all-cause mortality after endocarditis diagnosis (hazard ratio, 4.4 [95% CI, 3.42–5.72]; P <0.0001). Conclusions: The widespread adoption of TAVR and application to lower-risk patients makes understanding mechanisms of valve failure increasingly important. PVE is an established mechanism of prosthetic valve failure post-SAVR and TAVR with unclear differences between approaches. We herein demonstrate in the largest trials and registries of TAVR that PVE remains rare, but often fatal, in modern AVR experience and that there is no difference in incidence, predictors, or risk of PVE between TAVR and SAVR. Clinical Trial Registration: https://www.clinicaltrials.gov . Unique identifiers: NCT00530894 (PARTNER 1), NCT01314313 (PARTNER 1IA), NCT02184442 (PARTNER 1IB), NCT03222141 (PII S3HR), NCT03222128 (PII S3i).

Incidence and outcomes of infective endocarditis after transcatheter aortic valve implantation versus surgical aortic valve replacement

“…A metaanalysis of randomized trials in 3761 did not find an increased risk of IE in TAVI compared with SAVR [24]. Recently, the pooled analysis of all patients in PARTNER 1 and PARTNER 2 trials and registries reported that IE remains rare but often fatal in modern SAVR experience and that there was no difference in incidence, predictors, or risk of IE between TAVI and SAVR [25].…”

Impact of recent heart failure hospitalization on clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis from the PARTNER 2 trial and registries

“…Prior studies have evaluated the independent predictors of endocarditis following TAVR, and on multivariable analysis found, younger age, history of HF, need for permanent pacemaker placement, cardiac arrest, major bleeding, and sepsis were independently associated with an increased risk of endocarditis during follow‐up 19 . A recently published pooled analysis of patient‐level data from PARTNER 1 and 2 trials found no association between recent hospitalization for AS symptoms and endocarditis 20 . Nevertheless, the inclusion of PARTNER 1 patients who had high mortality rates, may have masked the effect of recent hospitalization on endocarditis due to competing risks.…”

“…19 A recently published pooled analysis of patient-level data from PARTNER 1 and 2 trials found no association between recent hospitalization for AS symptoms and endocarditis. 20 endogenous flora, depending on the length of hospitalization. 6 For example, bloodstream infections in patients who had been hospitalized for 2 or more days within 90 days prior to the infection were similar to nosocomial infections in terms of source of infection, pathogens and their antibiotic susceptibility patterns.…”

Infective endocarditis after TAVI: a meta-analysis and systematic review of epidemiology, risk factors and clinical consequences

“…The present study reported no significant difference for in-hospital, early, mid-term, or late incidence of IE between patients with TAVI or SAVR. Summers et al (2019) reported a PVE incidence rate of 5.06 [95% CI, 4.19 to 6.12] per 1,000 person-years in PARTNER trials with no statistical difference in the incidence of TAVR and SAVR-PVE (Incidence rate ratio [IRR] 1.27 [95% CI, 0.70 to 2.32; P = 0.44]).…”