Infective Endocarditis after Primary TAVI Procedure Treated by a Replacement by Edwards Intuity Valve: A Case Report

Introduction: Infective Endocarditis (IE) following TAVI procedure is a rare complication. Operability of these patients has to be considered carefully. Detection of endocarditis is difficult. Residual incompetence of the TAVI is often noticed and echocardiographic diagnostic procedures may be complex. We report on a patient who underwent a TAVI procedure in 2013 and developed endocarditis which was followed by an open replacement with the Intuity valve.

Case Report: A 83-year-old men, with a history of an TAVI replacement “Direct Flow Medical, 25mm” in 2013 and a balloon valvuloplasty, due to a re-stenosis 2015 presented with progredient exertional dyspnea. Physical examination showed cardiac decompensation and a midsystolic murmur. Medical history revealed therapy resistant atrial fibrillation, left brain stroke in 2013, COPD Gold I-II, sleep apnea (CPAP therapy), cardiac vascular risk factors: hypertension, obesity (BMI 29.4 kg/m²) as well as main steam and 1 vessel coronary heart disease (HS/RIVA/D1-PTCA). Blood tests revealed increased leucocytes and CRP. A transesophageal ultrasound was performed and showed a progressive gradient over the replaced aortic valve (Vmax: 3.9 m/s, MaxPG: 60 mm Hg, mean PG: 32 mm Hg) a stenosis of the artificial valve was diagnosed as well as a thickened leaflet tissue and restricted separation of the valve leaflets. Based on the medical history and the information of positive blood cultures (Enterococcus faecalis), the heart team indicated an open aortic valve replacement. EuroSCORE raised from 19% (2013) to 32% (2016). A replacement of the TAVI valve by an “Edwards Intuity, 21mm” and a reconstruction of the aortic ring after explantation of the Direct Flow prosthesis was performed. The final diagnosis was IE of the TAVI valve. The patient was discharged to rehab 12 days after surgery. At a 4-month follow-up visit, the patient was free of IE.

Conclusion: We learn, that once an operation is performed the surgeon is in charge, when procedure or prosthesis-associated complications occur even in TAVI-patients. That despite the calculated EuroSCORE values a surgical intervention has the potential to be successful without much effort, especially due to an Intuity procedure. Due to the large number of additional diseases in this patient a shorter procedure time, X-clamping time and a reduction of manipulation should be the state of the art in such cases, those requirements are likely possible by an Intuity replacement.