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Original Investigation
September 13, 2016

Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death

Ander Regueiro, MD1; Axel Linke, MD2; Azeem Latib, MD3; et al Nikolaj Ihlemann, MD4; Marina Urena, MD5; Thomas Walther, MD6; Oliver Husser, MD7; Howard C. Herrmann, MD8; Luis Nombela-Franco, MD,PhD9; Asim N. Cheema, MD10; Hervé Le Breton, MD, PhD11; Stefan Stortecky, MD12; Samir Kapadia, MD13; Antonio L. Bartorelli, MD14; Jan Malte Sinning, MD15; Ignacio Amat-Santos, MD, PhD16; Antonio Munoz-Garcia, MD17; Stamatios Lerakis, MD18; Enrique Gutiérrez-Ibanes, MD19; Mohamed Abdel-Wahab, MD20 ; Didier Tchetche, MD21; Luca Testa, MD22; Helene Eltchaninoff, MD23; Ugolino Livi, MD24; Juan Carlos Castillo, MD25; Hasan Jilaihawi, MD26; John G. Webb, MD27; Marco Barbanti, MD28; Susheel Kodali, MD29; Fabio S. de Brito Jr, MD30; Henrique B. Ribeiro, MD, PhD31; Antonio Miceli, MD32; Claudia Fiorina, MD33; Guglielmo Mario Actis Dato, MD34; Francesco Rosato, MD35; Vicenç Serra, MD36; Jean-Bernard Masson, MD37; Harindra C. Wijeysundera, MD38; Jose A. Mangione, MD39; Maria-Cristina Ferreira, MD40; Valter C. Lima, MD41; Luiz A. Carvalho, MD42; Alexandre Abizaid, MD, PhD43; Marcos A. Marino, MD44; Vinicius Esteves, MD45; Julio C. M. Andrea, MD46; Francesco Giannini, MD3; David Messika-Zeitoun, MD5; Dominique Himbert, MD5; Won-Keun Kim, MD6; Costanza Pellegrini, MD7; Vincent Auffret, MD11; Fabian Nietlispach, MD47; Thomas Pilgrim, MD12; Eric Durand, MD23; John Lisko, MD18; Raj R. Makkar, MD26; Pedro A. Lemos, MD, PhD31; Martin B. Leon, MD29; Rishi Puri, MBBS, PhD1; Alberto San Roman, MD16; Alec Vahanian, MD5; Lars Søndergaard, MD4; Norman Mangner, MD2; Josep Rodés-Cabau, MD1
Author Affiliations
  • 1Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
  • 2Heart Center, Leipzig University, Leipzig, Germany
  • 3EMO-GVM Centro Cuore Columbus and San Raffaele Scientific Institute, Milan, Italy
  • 4Rigshospitalet, Copenhagen, Denmark
  • 5Bichat Hôpital, AP-HP, University Paris Diderot, France
  • 6Kerckhoff Klinik, Bad Nauheim, Germany
  • 7Deutsches Herzzentrum München, Technische Universität München, DZHK, partner site Munich Heart Alliance, Munich, Germany
  • 8Hospital of the University of Pennsylvania, Philadelphia
  • 9Hospital Universitario Clinico San Carlos, Madrid, Spain
  • 10St Michaels Hospital, Toronto, Canada
  • 11Centre Hospitalier Universitaire de Rennes, Rennes, France
  • 12Bern University Hospital (on behalf of Swiss TAVI Registry Centres), Bern, Switzerland
  • 13Cleveland Clinic, Cleveland, Ohio
  • 14Centro Cardiologico Monzino, Milan, Italy
  • 15Heart Center Bonn, Bonn, Germany
  • 16Hospital Clinico Universitario de Valladolid, Valladolid, Spain
  • 17Hospital Universitario Virgen de la Victoria, Malaga, Spain
  • 18Emory University School of Medicine, Atlanta, Georgia
  • 19Hospital Gregorio Maranon, Madrid, Spain
  • 20 Heart Center, Segeberger Kliniken, Bad Segeberg, Germany
  • 21Clinique Pasteur, Toulouse, France
  • 22IRCCS Pol. San Donato, Milan, Italy
  • 23Hôpital Charles Nicolle, University of Rouen, INSERM U1096, France
  • 24Department of Cardiothoracic Surgery, University Hospital of Udine, Italy
  • 25Hospital Universitario Reina Sofia, Cordoba, Spain
  • 26Cedars-Sinai Heart Institute, Los Angeles, California
  • 27St Pauls Hospital, Vancouver, British Columbia, Canada
  • 28Ferrarotto Hospital, Catania, Italy
  • 29Columbia University Medical Center, New York, New York
  • 30Hospital Israelita Albert Einstein, Sao Paulo, Brazil
  • 31Heart Institute (InCor), Sao Paulo, Brazil
  • 32Fondazione Toscana G. Monasterio, Massa, Italy
  • 33Spedali Civili di Brescia, Brescia, Italy
  • 34Ospedale Mauriziano, Torino, Italy
  • 35Azienda Ospedaliera, S. Croce e Carle Cuneo, Cuneo, Italy
  • 36Hospital Vall d'Hebron, Barcelona, Spain
  • 37Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada
  • 38Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  • 39Hospital Beneficencia Portuguesa, Sao Paulo, Brazil
  • 40Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil
  • 41Hospital São Francisco-Santa Casa de Misericórdia de Porto Alegre, Brazil
  • 42Hospital Pró-cardíaco, Rio de Janeiro, Brazil
  • 43Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
  • 44Hospital Madre Teresa, Belo Horizonte, Brazil
  • 45Hospital Sao Luiz, Sao Paulo, Brazil
  • 46Clínica Sao Vicente, Rio de Janeiro, Brazil
  • 47University Hospital Zurich, Zurich, Switzerland
JAMA. 2016;316(10):1083-1092. doi:10.1001/jama.2016.12347
Abstract

Importance  Limited data exist on clinical characteristics and outcomes of patients who had infective endocarditis after undergoing transcatheter aortic valve replacement (TAVR).

Objective  To determine the associated factors, clinical characteristics, and outcomes of patients who had infective endocarditis after TAVR.

Design, Setting, and Participants  The Infectious Endocarditis after TAVR International Registry included patients with definite infective endocarditis after TAVR from 47 centers from Europe, North America, and South America between June 2005 and October 2015.

Exposure  Transcatheter aortic valve replacement for incidence of infective endocarditis and infective endocarditis for in-hospital mortality.

Main Outcomes and Measures  Infective endocarditis and in-hospital mortality after infective endocarditis.

Results  A total of 250 cases of infective endocarditis occurred in 20 006 patients after TAVR (incidence, 1.1% per person-year; 95% CI, 1.1%-1.4%; median age, 80 years; 64% men). Median time from TAVR to infective endocarditis was 5.3 months (interquartile range [IQR], 1.5-13.4 months). The characteristics associated with higher risk of progressing to infective endocarditis after TAVR was younger age (78.9 years vs 81.8 years; hazard ratio [HR], 0.97 per year; 95% CI, 0.94-0.99), male sex (62.0% vs 49.7%; HR, 1.69; 95% CI, 1.13-2.52), diabetes mellitus (41.7% vs 30.0%; HR, 1.52; 95% CI, 1.02-2.29), and moderate to severe aortic regurgitation (22.4% vs 14.7%; HR, 2.05; 95% CI, 1.28-3.28). Health care–associated infective endocarditis was present in 52.8% (95% CI, 46.6%-59.0%) of patients. Enterococci species and Staphylococcus aureus were the most frequently isolated microorganisms (24.6%; 95% CI, 19.1%-30.1% and 23.3%; 95% CI, 17.9%-28.7%, respectively). The in-hospital mortality rate was 36% (95% CI, 30.0%-41.9%; 90 deaths; 160 survivors), and surgery was performed in 14.8% (95% CI, 10.4%-19.2%) of patients during the infective endocarditis episode. In-hospital mortality was associated with a higher logistic EuroSCORE (23.1% vs 18.6%; odds ratio [OR], 1.03 per 1% increase; 95% CI, 1.00-1.05), heart failure (59.3% vs 23.7%; OR, 3.36; 95% CI, 1.74-6.45), and acute kidney injury (67.4% vs 31.6%; OR, 2.70; 95% CI, 1.42-5.11). The 2-year mortality rate was 66.7% (95% CI, 59.0%-74.2%; 132 deaths; 115 survivors).

Conclusions and Relevance  Among patients undergoing TAVR, younger age, male sex, history of diabetes mellitus, and moderate to severe residual aortic regurgitation were significantly associated with an increased risk of infective endocarditis. Patients who developed endocarditis had high rates of in-hospital mortality and 2-year mortality.

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