Is antibiotic prophylaxis required before dental work for patients with Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Yes, antibiotic prophylaxis is recommended before dental procedures for patients with Transcatheter Aortic Valve Replacement (TAVR). The standard regimen is amoxicillin 2 grams orally taken 30-60 minutes before the dental procedure, as recommended by the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines 1. For patients allergic to penicillin, alternatives include clindamycin 600 mg, azithromycin 500 mg, or clarithromycin 500 mg orally 30-60 minutes before the procedure. This prophylaxis is needed for all dental procedures that involve manipulation of gingival tissue, perforation of the oral mucosa, or procedures involving the periapical region of teeth.

The rationale behind this recommendation is that TAVR valves, like other prosthetic heart valves, carry an increased risk of infective endocarditis, as noted in the 2017 AHA/ACC guidelines 1. Bacteremia from dental procedures can lead to bacteria colonizing the prosthetic valve material, potentially causing a life-threatening infection. The risk is highest during the first year after valve implantation but remains throughout the patient's life. Patients should inform all dental providers about their TAVR valve to ensure appropriate prophylaxis is administered before procedures.

Some key points to consider:

• The 2017 AHA/ACC guidelines recommend antibiotic prophylaxis for patients with TAVR valves before dental procedures that involve manipulation of gingival tissue, perforation of the oral mucosa, or procedures involving the periapical region of teeth 1.
• The European Society of Cardiology (ESC) also recommends antibiotic prophylaxis for patients with prosthetic valves, including TAVR valves, before dental procedures that involve manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa 1.
• The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines emphasize the importance of maintaining optimal oral health through regular professional dental care and the use of appropriate dental products to reduce the risk of infective endocarditis 1.

Overall, the current evidence supports the use of antibiotic prophylaxis before dental procedures for patients with TAVR valves to reduce the risk of infective endocarditis.

From the Research

Antibiotic Prophylaxis for TAVR Patients Undergoing Dental Work

• The American Heart Association (AHA) has guidelines for the prevention of infective endocarditis through antibiotic prophylaxis protocol 2.
• However, the actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance 2.
• There is no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure 3.
• The incidence of bacterial endocarditis is low, but it has a high mortality rate, and guidelines in many countries have recommended that antibiotics be administered to people at high risk of endocarditis prior to invasive dental procedures 3.
• The National Institute for Health and Care Excellence (NICE) in England and Wales states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures 3.

Specific Recommendations for TAVR Patients

• Prophylaxis of endocarditis during dental procedures in patients with known valve disease should be aimed at reducing the number of bacteria entering the blood stream and eliminating those that get there 4.
• Good oro-dental hygiene and the use of prophylactic antibiotics can help reduce the risk of infective endocarditis 4.
• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend antibiotic prophylaxis only in patients at high risk for IE, which may include TAVR patients 5.
• Alternative, effective, and harmless measures for the prevention of IE in patients at low risk may be considered 5.

Antibiotic Regimens

• Amoxicillin/clavulanic acid and moxifloxacin may be considered for antibiotic prophylaxis due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics 2.
• Amoxicillin is the main recommendation in patients who are not allergic to penicillin, while clindamycin orally or vancomycin intravenously are proposed for patients allergic to penicillin 6.
• Aminoglycosides may be added for gastrointestinal or urological procedures 6.