Do patients who have undergone Transcatheter Aortic Valve Replacement (TAVR) require prophylactic antibiotics prior to dental extractions?

Antibiotic Prophylaxis for TAVR Patients Undergoing Dental Extractions

Prophylactic antibiotics are reasonable before dental extractions in patients who have undergone Transcatheter Aortic Valve Replacement (TAVR), as these patients fall into the high-risk category with prosthetic cardiac valves. 1

Risk Assessment and Rationale

TAVR patients are specifically identified in current guidelines as a high-risk population requiring antibiotic prophylaxis before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of oral mucosa. This includes dental extractions, which clearly fall into this category 1.

The 2017 AHA/ACC guidelines explicitly state that patients with "prosthetic cardiac valves, including transcatheter-implanted prostheses" should receive prophylaxis 1. This recommendation is maintained in the 2020 ACC/AHA guidelines for valvular heart disease management 1.

Key points supporting this recommendation:

• TAVR valves are considered prosthetic cardiac valves
• Infective endocarditis (IE) has been reported to occur after TAVR at rates equal to or exceeding those associated with surgical aortic valve replacement
• IE in TAVR patients is associated with a high 1-year mortality rate of approximately 75% 1

Recommended Antibiotic Regimen

For adults undergoing dental extractions who have had TAVR, the recommended prophylactic regimen is:

Standard regimen:

• Amoxicillin 2g orally 30-60 minutes before the procedure 1, 2

For patients allergic to penicillin:

• Clindamycin 600mg orally 30-60 minutes before the procedure, OR
• Azithromycin or clarithromycin 500mg orally 30-60 minutes before the procedure 1, 2

For patients unable to take oral medication:

• Ampicillin 2g IM or IV, OR
• Cefazolin or ceftriaxone 1g IM or IV
• For penicillin-allergic patients: Clindamycin 600mg IM or IV 1

Evidence and Limitations

Despite the clear guidelines, it's important to note that the evidence supporting antibiotic prophylaxis is limited:

• A 2013 Cochrane review concluded there is no evidence to determine whether antibiotic prophylaxis is effective or ineffective in preventing IE 3
• A 2022 update of this review maintained this conclusion, with very low certainty of evidence 4

However, a recent 2022 study provides stronger evidence supporting prophylaxis. This case-crossover analysis and cohort study of nearly 8 million subjects demonstrated:

• A significant temporal association between invasive dental procedures and subsequent IE in high-risk individuals
• A significant association between antibiotic prophylaxis use and reduced IE incidence following these procedures
• The strongest association was for dental extractions (OR: 11.08) and oral-surgical procedures (OR: 50.77) 5

Important Considerations

1. Timing is critical: Administer antibiotics 30-60 minutes before the procedure to ensure adequate tissue levels at the time of bacterial exposure 2

2. Oral hygiene importance: Maintaining optimal oral hygiene is as important as antibiotic prophylaxis for preventing IE 2

3. Procedure specificity: Prophylaxis is only needed for procedures involving gingival manipulation, periapical region manipulation, or oral mucosa perforation 1

4. Risk-benefit assessment: While the absolute risk reduction may be small, the high mortality rate associated with IE in TAVR patients justifies prophylaxis 1

5. Enterococcal risk: Recent research suggests that TAVR patients may be at particular risk for enterococcal IE, which may not be covered by standard cephalosporin prophylaxis 6

Given the high mortality associated with IE in TAVR patients and the recent evidence supporting prophylaxis efficacy, antibiotic prophylaxis remains reasonable for TAVR patients undergoing dental extractions, despite some limitations in the overall evidence base.