Is prophylactic antibiotic therapy required for a patient with a history of prior Transcatheter Aortic Valve Replacement (TAVR) undergoing a procedure?

Prophylactic Antibiotics for Procedures in Patients with Prior TAVR

Yes, prophylactic antibiotics are recommended for patients with a history of TAVR when undergoing high-risk dental procedures that involve manipulation of gingival tissue or the periapical region of teeth. 1

Which Procedures Require Prophylaxis

Dental procedures only:

• Antibiotic prophylaxis is indicated for dental procedures requiring manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa 1
• This includes routine dental cleaning 1

Non-dental procedures do NOT require prophylaxis:

• Gastrointestinal procedures (esophagogastroscopy, colonoscopy) 1
• Genitourinary procedures (cystoscopy) 1
• Respiratory tract procedures (bronchoscopy, transesophageal echocardiography) 1
• Skin and soft tissue procedures 1

Rationale for TAVR-Specific Prophylaxis

The 2017 AHA/ACC guidelines specifically added transcatheter-implanted prosthetic valves to the highest-risk category requiring prophylaxis 1. This change was based on:

• Infective endocarditis occurs after TAVR at rates equal to or exceeding surgical aortic valve replacement 1
• Associated with 75% one-year mortality rate when IE develops post-TAVR 1
• Observational studies demonstrate increased risk of developing IE and high risk of adverse outcomes in this population 1

Antibiotic Regimen for Dental Procedures

Standard oral regimen (if able to take oral medications):

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

If unable to take oral medications:

• Ampicillin 50 mg/kg IM or IV (adult dose: 2 grams), OR
• Cefazolin or ceftriaxone 50 mg/kg IM or IV (adult dose: 1 gram) 1

If penicillin allergic (oral):

• Cephalexin 2 grams orally, OR
• Clindamycin 600 mg orally, OR
• Azithromycin or clarithromycin 500 mg orally 1

If penicillin allergic (unable to take oral):

• Cefazolin or ceftriaxone 1 gram IM or IV (avoid if history of anaphylaxis to penicillin), OR
• Clindamycin 600 mg IM or IV 1

Critical Caveats

Timing is essential: The preoperative dose must be given 30-60 minutes before the procedure to ensure adequate antibiotic levels are present at the time of bacterial exposure 1

Only a single dose is needed for dental procedures—do not continue prophylaxis beyond the procedure 1

Optimal oral hygiene is paramount: Daily oral health maintenance and regular professional dental care are more important than prophylaxis for individual procedures, as most IE cases result from daily bacteremia rather than dental procedures 1

Post-TAVR Long-Term Management

The 2017 ACC Expert Consensus recommends:

• Encourage optimal dental care as part of routine follow-up 1
• Apply antibiotic prophylaxis per AHA/ACC guidelines for all dental procedures 1
• Establish regular dental review to prevent IE 1

High-Risk Pathogen Considerations

If IE develops post-TAVR, be aware that:

• Staphylococcus aureus is the most common pathogen (35% of very early IE cases), with 31% being methicillin-resistant 2
• Enterococci are the second most common (34% of cases) 2
• Very early IE (≤30 days post-TAVR) carries 44% in-hospital mortality and 54% one-year mortality 2