Surgery for Transcatheter Aortic Valve Replacement Endocarditis—A Single-Center Series

Objectives: Transcatheter aortic valve replacement (TAVR) is increasingly being used for the treatment of aortic valve stenosis. Overall, the total number of patients with an aortic valve prosthesis increases and so does the incidence of prosthetic endocarditis. Infective endocarditis (IE) following TAVR is a rare but more frequently occurring complication. In many cases, surgery remains the only treatment option for IE. We report on seven patients with IE after previous TAVR treated by surgical TAVR explantation and open valve replacement.

Methods: Between March 2016 and August 2018, seven patients were operated for IE after TAVR. The TAVR models included three Direct Flow valves, two Edwards S3, and two CoreValve. Patients were identified in our institutional database and analyzed retrospectively regarding their demographics, comorbidities, operative details, postoperative course, and outcome. Mean age was 80.5 ± 2.6 years; six men and one women.

Results: IE was diagnosed 14 ± 13 months after TAVR. The following bacteria could be detected microbiologically: five of seven patients’ blood cultures were positive for Enterococcus faecalis, one for Staphylococcus epidermidis, and one for Staphylococcus dysgalactiae. Indication for reoperation were large floating structures in five of seven patients, sepsis with hypotension in five of seven, and severe aortic regurgitation in one of seven patients. Median EuroSCORE II was 23.6%. Open valve replacement required annular patch plastic in six of seven patients. Mean cardiopulmonary bypass time and cross-clamp time were 106 ± 35 and 83 ± 32 minutes, respectively. Concomitant cardiac procedures were mitral valve repair (four of seven) and coronary artery bypass grafting in one of seven patients. Mean size of the surgically replaced aortic prosthesis was significantly smaller compared with the previously implanted TAVR (27.9 ± 1.5 vs. 24 ± 1.3 mm, p < 0.001) with a mean gradient of 6.7 ± 3.5 mm Hg. Median ventilation time and in-hospital stay duration were 9.7 hours and 15 days, respectively. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 8 ± 7 months.

Conclusion: With an increasing number of patients after TAVR, prosthetic endocarditis will increasingly occur in patients who were previously considered high risk. Our results show that patients with TAVR infective endocarditis can be operated with excellent results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis.