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Surgery in Patients following Infective Endocarditis after Primary TAVI Procedure: A Single-Center Series
13 February 2020 (online)
Objectives: Transcatheter aortic valve replacement (TAVR) is increasingly being used for the treatment of aortic valve stenosis, even in intermediate and low risk patients. Therefore, the total number of patients with an aortic valve prosthesis increases and so does the incidence of prosthetic endocarditis. Infective endocarditis (IE) following TAVR is a more frequently occurring complication. In many cases surgery remains the only treatment option. We report on 10 patients with IE after previous TAVR treated by surgical aortic valve replacement (SAVR).
Methods: Between March 2016 and July 2019 ten patients were operated for IE after TAVR. The models included three direct flow valves, four Edwards S3, three Medtronic Evolut R. Patients were identified in our institutional database and analyzed retrospectively regarding their demographics, comorbidities, operative details, postoperative course and outcome. Mean age was 79 ± 4.4 years, seven men and three women.
Results: IE was diagnosed 17 ± 16 month after TAVR. The following bacteria could be detected microbiologically, 5/10 patients’ blood cultures were positive for Enterococcus faecalis, 1 for Staphylococcus epidermidis, one for Staphylococcus dysgalactiae, and one for Streptococcus bovis. Indication for reoperation was large floating structures in 8/10 patients, sepsis with hypotension in 5/10, and severe aortic regurgitation in 3/10 patients. Median Euroscore II was 24.64%. Open valve replacement required annular patch plastic in 8/10 patients. Mean cardiopulmonary bypass time and cross-clamp time were 119 ± 45 minutes and 85 ± 26 minutes, respectively. Concomitant cardiac procedures were mitral valve repair/replacement (4/10) and CABG in 1/7 patients. Mean size of the surgically replaced aortic prosthesis was smaller compared to the previously implanted TAVR (23.6 ± 1.3 vs. 28.4 ± 2.3 mm, p < 0.003) with a mean gradient of 8.5 ± 2.2 mm Hg. Median ventilation time and ICU stay duration were 20 hours and 14 days. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 9 ± 8 months.
Conclusion: With a progressive number of patients after TAVR, prosthetic endocarditis will increasingly occur in patients who were previously considered high or intermediate risk. Our results show that patients with TAVR infective endocarditis can be operated with excellent results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis.