What is the recommended antibiotic prophylaxis for patients who have undergone Transcatheter Aortic Valve Replacement (TAVR) before dental procedures?

Antibiotic Prophylaxis for Dental Procedures After TAVR

Patients who have undergone Transcatheter Aortic Valve Replacement (TAVR) should receive antibiotic prophylaxis before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa.

High-Risk Cardiac Conditions Requiring Prophylaxis

The American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines specifically identify patients with transcatheter prosthetic valves as being at high risk for infective endocarditis (IE) and recommend antibiotic prophylaxis for dental procedures in these patients:

• Patients with prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts 1
• Patients with prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords 1
• Patients with previous IE 1
• Patients with unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation at or adjacent to prosthetic material 1
• Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve 1

Dental Procedures Requiring Prophylaxis

Antibiotic prophylaxis is recommended for high-risk patients (including TAVR patients) undergoing:

• Dental procedures involving manipulation of gingival tissue 1
• Procedures involving manipulation of the periapical region of teeth 1
• Procedures involving perforation of the oral mucosa 1

Prophylaxis is NOT recommended for:

• Local anesthetic injections in non-infected tissues 1
• Treatment of superficial caries 1
• Removal of sutures 1
• Dental X-rays 1
• Placement or adjustment of removable prosthodontic or orthodontic appliances 1
• Following shedding of deciduous teeth or trauma to lips/oral mucosa 1

Recommended Antibiotic Regimens

Standard regimen (no allergy to penicillin):

• Amoxicillin 2g orally 1 hour before procedure (adults) 1
• Amoxicillin 50 mg/kg orally 1 hour before procedure (children) 1

For patients allergic to penicillin:

• Clindamycin 600mg orally 1 hour before procedure (adults) 1
• Clindamycin 20 mg/kg orally 1 hour before procedure (children) 1

Alternative for patients allergic to penicillin (without history of anaphylaxis, angioedema, or urticaria):

• Cephalexin 2g orally (adults) or 50 mg/kg orally (children) 1, 2
• Azithromycin 500mg orally (adults) or 15 mg/kg orally (children) 3, 4

Rationale and Evidence

The recommendation for antibiotic prophylaxis in TAVR patients is based on:

• IE has been reported to occur after TAVR at rates equal to or exceeding those associated with surgical aortic valve replacement 1
• TAVR-associated IE is associated with a high 1-year mortality rate of 75% 1
• Recent research has demonstrated a significant temporal association between invasive dental procedures (particularly extractions and oral surgical procedures) and subsequent IE in high-risk individuals 5
• The same research showed a significant association between antibiotic prophylaxis use and reduced IE incidence following these procedures 5

Important Considerations

• Oral amoxicillin remains the antibiotic of choice to reduce bacteremia in patients without penicillin allergies 4
• In patients with penicillin allergies, oral azithromycin showed higher efficacy for the reduction of bacteremia compared to clindamycin in some studies 4
• Maintenance of optimal oral health through regular professional dental care and good oral hygiene is critically important for reducing IE risk 1
• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac/intravascular foreign material 1, 2

Common Pitfalls to Avoid

• Failing to provide prophylaxis for TAVR patients undergoing high-risk dental procedures 1
• Using inappropriate antibiotic regimens or incorrect timing (antibiotics should be administered 30-60 minutes before the procedure) 4
• Neglecting the importance of regular dental care and good oral hygiene in preventing IE 1
• Providing unnecessary prophylaxis for low-risk dental procedures or non-dental procedures in the absence of active infection 1
• Using fluoroquinolones or glycopeptides for prophylaxis, which is not recommended due to unclear efficacy and potential induction of resistance 1

Recent evidence supports the continued use of antibiotic prophylaxis in patients with TAVR undergoing dental procedures that manipulate gingival tissue or the periapical region of teeth, as these patients are at increased risk of developing IE with high associated mortality 1, 5.