After a Successful TAVI A Nasty Surprise After a Successful TAVI 20 Andrew Cassar, Mark Abela, Albert Fenech Mater Dei Hospital, MALTA

Speaker’s name: Andrew Cassar ❒ I have the following potential conflicts of interest to report: ❒ Consulting ❒ Employment in industry ❒ Stockholder of a healthcare company ❒ Owner of a healthcare company ❒ Other(s)  I do not have any potential conflict of interest

Presentation 85 year old gentleman PVD (toe amputation), AF, CHF Several hospital admissions since Jan 09 with chest pain, pulm oedema, and recurrent pleural effusion Dec 09 found to have severe AS on TTE: Max Vel 5.8m/s, Max Grad 133mmHg, Mean 90mmHg, AVA 0.7 cm2 Logistic Euroscore 11% STS 6.5% Turned down for SAVR by cardiac surgeons due to high risk

Balloon Aortic Valvuloplasties February 2011 during readmission for pulm oedema pt underwent successful BAV (gradient down to 40 mmHg) Cor angio showed significant disease in small RCA Patient was well for a few months and was scheduled for a TF TAVI in July 2011 In the end of June 2011 admitted with pulm oedema and deterioration in general condition, hypotension, anorexia Repeat BAV was done with minimal improvement Scheduled for trans-aortic TAVI 4 days later

l TAVI procedure Edwards Sapien valve successfully deployed via ascending aorta route Under General anaesthesia, CV line, TOE Pigtail and temporary pacemaker via Right groin 1g of i.v. Vancomycin prophylaxis given at induction

Post-TAVI 3 days in ICU Intensive physiotherapy during admission Discharged after 22 days Improved NYHA & Pressure Gradient

Patient Presentation Post-TAVI Patient re-admitted 2 days post-discharge with deterioration in general condition, unable to swallow, anorexic, On examination, patient was noted to be dehydrated, afebrile, few basal crepitations R>L – Impression: Chest infection and Dehydration Patient was started on IV fluids, Naso-Gastric Tube inserted and co-amoxiclav 1.2g tds in view of a possible pneumonia – patient steadily improved ESR 44 and CRP 73, normal WCC

An ECHO showed a large (25 x 5 mm) vegetation at the base of the posterior leaflet of the mitral valve that was prolapsing in the LA with minimal MR. Prosthetic Aortic Valve was intact with mild paravalvular leakage.

Management of IE Two sets of blood cultures were taken. Patient was started empirically with Gentamicin and Vancomycin. Enterococcus faecalis was cultured, Pathogen sensitive to amoxicillin and antibiotic changed accordingly. Patient general condition improved, ESR and CRP came down

Why did the IE happen? IE is a known complication of BAV (3 case reports all aortic IE) IE is a known complication of TAVI (1% of SOURCE registry patients in 1 yr) Incidental? Recurrent interventions (2 BAV + 1 TAVI) may have put patient at a higher risk of endocarditis Why mitral IE not aortic? Circulation. 2011 Jul 26;124(4):425-33 Ann Thorac Surg. 1993 Nov;56(5):1161-2 Am Heart J. 1988 Jan;115(1 Pt 1):178-9 Am Heart J. 1992 Jul;124(1):223-5.

Learning experience IE tends to have atypical and insidious presentations in the elderly Don’t rush off to intervention if patients waiting for a TAVI deteriorate suddenly Should we give antibiotic prophylaxis before BAV? Does delaying TAVI increase risk? Should Vancomycin have been given earlier?

Thank You!