1. TAVR-Endocarditis Tarek Chami, MD
Morbidity and Mortality

2. Disclosure
None

3. 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?

4. .

5. 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): doi: /eurheartj/ehq406

6. .

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

8. 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

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

10. Which approach is associated with more TAVR-Endocarditis?

11. 29 of 2,572 pts in 14 centers between January 2008 and April 2013
Early (<60 dys), Intermediate ( 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

12. 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

13. . 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

14. 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)

15. 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

16. .
Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, (10): p

17. .
Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, (10): p

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

20. 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.

21. 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.

22. References
Brecker, S.J. Transcatheter aortic valve implantation: Periprocedural management. Feburay 13, 2017]; Available from:
Leon, M.B., et al., Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med, (17): p
Latib, A., et al., TAVR-associated prosthetic valve infective endocarditis: results of a large, multicenter registry. J Am Coll Cardiol, (20): p
Amat-Santos, I.J., et al., Prosthetic valve endocarditis after transcatheter valve replacement: a systematic review. JACC Cardiovasc Interv, (2): p
Mylotte, D., et al., Transcatheter heart valve failure: a systematic review. Eur Heart J, (21): p
Regueiro, A., et al., Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death. JAMA, (10): p
Cahill, T.J., et al., Challenges in Infective Endocarditis. J Am Coll Cardiol, (3): p
Van Kesteren, F., et al., Autopsy after transcatheter aortic valve implantation. Virchows Arch, 2017.
Others: Transcarotid, Transcaval, subclavian

23. Questions? Thank you!!