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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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.

9. 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

10. 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 Jul 26;124(4):425-33
Ann Thorac Surg Nov;56(5):1161-2
Am Heart J Jan;115(1 Pt 1):178-9
Am Heart J Jul;124(1):223-5.

11. 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?

12. Thank You!