TAVR-Endocarditis Tarek Chami, MD Morbidity and Mortality 2.17.2017

Disclosure None

Goals and objectives What are the three different approaches to TAVR and which, if any, are most closely associated with infection? Could you show images of the vegetation seen on TEE? What are the options for treatment of TAVR-associated endocarditis? Can the infected device be removed?

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Valves Balloon-expandable, stainless steel support structure, bovine pericardial valve “Edwards Sapien” (Edwards Lifesciences, Irvine, California) Self-expandable, nitinol support structure, porcine pericardial valve “CoreValve” (Medtronic, Minneapolis, Minnesota) Eur Heart J. 2010;32(2):205-217. doi:10.1093/eurheartj/ehq406

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Transfemoral (TF) Most common (> 50-95% in some registries) More Favorable Unsuitable ileofemoral art. anatomy Retrograde

Transapical (TA) 2nd most common. Direct left ventricular apical puncture through small anterolateral thoracotomy Pros: porcelain aorta, severe PAD Cons: longer length of stay, more invasive Antegrade

Transaortic (TAo) Least common. Aortotomy through small median sternotomy or lateral thoracotomy at the second intercostal space Pros: less painful, faster recovery Retrograde

Which approach is associated with more TAVR-Endocarditis?

29 of 2,572 pts in 14 centers between January 2008 and April 2013 Early (<60 dys), Intermediate (60-365 dys), and Late (> 365 dys) Diagnosis of early-onset TAVR-PIE was established in 28% (8 of 29), intermediate-onset in 52% (15 of 29) and late-onset in 20% (6 of 29) Incidence of TAVR-PIE was 1.1% (23 of 2133) and 1.98% (6 of 303) after transfemoral and transapical TAVR, respectively Latib et al. JACC 2014

53 of 7944 pts in 21 centers in North America, South America, and Europe from 2007 to 2014 40 patients (75.5%) developing the initial symptoms of IE within the year after TAVI No specific approach was associated with increase risk for TAVR-Endocarditis Amat-Santos et al. Circ 2015

. 250 of 20,006 pts in 47 centers worldwide Early infective endocarditis occurred in 178 patients (71.2%; 95% CI, 65.6%-76.8%) including 72 patients (28.8%; 95% CI, 23.2%-34.4%) diagnosed within 2 months of the procedure TF was not associated with increase rate of infective endocarditis after TAVR . Regueiro et al. JAMA 2016

Balloon-expandable Self-expandable Latib et al. 1.93% (23 of 1,191) 0.45% (6 of 1,343) Amat-Santons et al. 5.4% (34 of 6329) 12.1% (19 of 1562) Regueiro et al. 1.8% (66 of 3637) 1.5% (42 of 2761)

Echo findings Vegetations: Up to 70% Perivalvular complications: abscess, fistula, pseudoanerysm Mitral valve involvement Amat-Santos et al. Circ 2015 Regueiro et al. JAMA 2016

. Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, 2016. 316(10): p. 1083-92

. Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, 2016. 316(10): p. 1083-92

Treatment & Outcomes Surgery +/- Explantation Transcatheter Valve in Valve “TViV” Antibiotics alone Others: Transcarotid, Transcaval, subclavian

Latib et al. Three patients (3 of 29) underwent surgery and 1 underwent TAVR-in-TAVR (1 of 29), whereas the others were treated medically. Mortality rate was 45% In-hospital and 62% at 2-years follow up. Amat-Santos et al. 11% underwent intervention (6 of 53. TViV: 2). In hospital mortality rate 50% and 66% at 1-year. Regueiro et al. 82% had an indication for surgery, but only 18% (47 of 250. TViV: 3) had an intervention. In hospital mortality rate 36% and 66.6% at 2-years.

Take home messages TF is the most common approach for TAVR. No difference in the rate of TAVR-Endocarditis between TF and TA. The majority of TAVR-Endocarditis has an indication for surgery, but very few get any intervention.

References Brecker, S.J. Transcatheter aortic valve implantation: Periprocedural management. Feburay 13, 2017]; Available from: https://www.uptodate.com/contents/transcatheter-aortic-valve-implantation-periprocedural-management?source=search_result&search=tavr&selectedTitle=3~42. Leon, M.B., et al., Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med, 2010. 363(17): p. 1597-607. Latib, A., et al., TAVR-associated prosthetic valve infective endocarditis: results of a large, multicenter registry. J Am Coll Cardiol, 2014. 64(20): p. 2176-8. Amat-Santos, I.J., et al., Prosthetic valve endocarditis after transcatheter valve replacement: a systematic review. JACC Cardiovasc Interv, 2015. 8(2): p. 334-46. Mylotte, D., et al., Transcatheter heart valve failure: a systematic review. Eur Heart J, 2015. 36(21): p. 1306-27. Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, 2016. 316(10): p. 1083-92. Cahill, T.J., et al., Challenges in Infective Endocarditis. J Am Coll Cardiol, 2017. 69(3): p. 325-344. Van Kesteren, F., et al., Autopsy after transcatheter aortic valve implantation. Virchows Arch, 2017. Others: Transcarotid, Transcaval, subclavian

Questions? Thank you!!