From the Guidelines
Infective TAVI explantation is a life-threatening condition that requires prompt surgical intervention, with the most recent evidence suggesting that surgical explantation offers the best chance for cure in appropriate candidates, despite high operative risk. The literature indicates that prosthetic valve endocarditis following TAVI occurs in approximately 0.5-3.1% of cases, with mortality rates ranging from 30-60% 1. When infection develops, surgical explantation becomes necessary when antibiotic therapy fails to control the infection.
Key Considerations
- The surgical approach typically involves a median sternotomy with cardiopulmonary bypass, allowing for complete removal of the infected transcatheter valve and any associated vegetations or abscesses.
- Antibiotic therapy should be initiated empirically with vancomycin (15-20 mg/kg IV every 12 hours) plus ceftriaxone (2g IV daily) or gentamicin (3-5 mg/kg IV daily) pending culture results, then tailored based on identified pathogens, typically continuing for 6 weeks postoperatively.
- Surgical challenges include the presence of the metallic frame embedded in native tissues, calcified annulus, and potential paravalvular leakage.
- Outcomes are influenced by patient comorbidities, timing of intervention, and causative organisms, with Staphylococcus species carrying worse prognoses.
Management Strategies
- Early surgical consultation is crucial when infection is suspected, as delayed intervention correlates with increased mortality.
- Postoperative management requires close monitoring for complications including heart block, paravalvular leak, and recurrent infection.
- The risk of developing infective endocarditis is highest in patients with a prosthetic valve, prior infective endocarditis, or congenital heart disease with residual flow disturbances 1.
- Transient bacteremia is commonly seen in routine activities, but the incidence of infective endocarditis after most procedures is low, with no controlled data supporting the benefit of antibiotic prophylaxis 1.
Evidence-Based Recommendations
- The 2021 ACC/AHA guideline for the management of patients with valvular heart disease recommends that patients with prosthetic valve endocarditis should be treated with antibiotic therapy and considered for surgical intervention if antibiotic therapy fails to control the infection 1.
- The American Heart Association scientific statement on vascular graft infections, mycotic aneurysms, and endovascular infections recommends that patients with infected endovascular devices should be treated with antibiotic therapy and considered for surgical explantation if antibiotic therapy fails to control the infection 1.
From the Research
Infective Endocarditis after TAVI
Infective endocarditis (IE) is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI) [(2,3,4)]. The incidence of IE after TAVI varies from 0.2% to 3.1% at 1 year post-implant 4.
Risk Factors for TAVI-IE
Several risk factors have been identified for the development of TAVI-IE, including:
- Male gender 3
- Intubation 3
- New pacemaker implantation 3
- Chronic kidney disease (CKD) 3
- Younger age at implant 4
- Significant residual aortic regurgitation 4
Microbiological Profile of TAVI-IE
The most common causative organisms of TAVI-IE are:
- Enterococci (25.9%) 5
- Staphylococcus aureus (16.1%) 5
- Coagulase-negative Staphylococcus species (14.7%) 5
Clinical Outcomes of TAVI-IE
The clinical outcomes of TAVI-IE are poor, with:
- High in-hospital mortality (29.5%) 5
- High mortality at follow-up (29.9%) 5
- High incidence of heart failure (37.1%) 5
- High incidence of major bleeding (11.3%) 5
- High incidence of septic shock (10-27.7%) 5
Treatment of TAVI-IE
The treatment of TAVI-IE is challenging and often requires a multidisciplinary approach [(2,3,4)]. Surgical intervention may be necessary in some cases, but it is associated with a high risk of complications 2.
Prevention of TAVI-IE
Prevention of TAVI-IE is crucial, and measures such as: