Infectious endocarditis with post-TAVR stroke: “dysmal” prognosis

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Patients suffering from a stroke during hospitalization for infectious endocarditis (IE) then catheter aortic valve replacement (TAVR) have a sad prognosis, with more than half of deaths during hospitalization with index and two-thirds during the first year, according to a new study.

The study, the first to evaluate stroke as an IE-related complication after TAVR in a large multicenter cohort, is published to the May 11 issue of Journal of the American College of Cardiology.

The authors, led by David del Val, MD, Quebec Heart & Lung Institute, Quebec, Canada, explain that IE after TAVR is a rare but serious complication associated with a high mortality rate. Neurological events, especially stroke, remain one of the most common and potentially disabling complications related to IE, but to date no study has attempted to assess predictors of stroke and outcomes in patients with IE following TAVR. .

For the current study, the authors analyzed data on infectious endocarditis after the international TAVR registry, including 569 patients who developed definitive IE after TAVR from 59 centers in 11 countries.

Patients who experienced a stroke during IE admission were compared with those who did not have a stroke.

The results showed that 57 patients (10%) had a stroke during IE hospitalization, with no differences in the causative microorganism between groups. Stroke patients had higher rates of stroke acute renal failure, systemic and persistent embolization bacteremia.

Factors associated with an increased risk of stroke during hospitalization for IE index included stroke before EI, moderate or higher residual aortic insufficiency after TAVR, balloon expandable valves, IE in the 30 days following TAVR and a vegetation size> 8 mm.

The stroke rate was 3.1% in patients with any of these risk factors; 6.1% with 1 risk factor; 13.1% with 2 risk factors; 28.9% with 3 risk factors and 60% with 4 risk factors.

“The presence of these factors (especially in combination) can be considered to determine earlier and more aggressive treatment (medical or surgical) in these patients,” the researchers say.

Patients with IE with stroke had higher rates of hospital mortality (54.4% vs. 28.7%) and 1-year overall mortality (66.3% vs. 45.6%).

Surgery rates were low (25%) even in the presence of stroke and failed to improve the outcomes of this population.

Noting that the agreed guidelines for managing patients with IE recommend surgery along with antibiotic treatment for patients who develop systemic embolism, particularly stroke, the researchers say their findings suggest that these surgical recommendations may not be extrapolated. to patients with TAVR-IE and that specific guidelines for this particular population are justified.

In addition, the possibility of early surgery in those patients with factors that increase the risk of stroke in future studies should be evaluated.

The authors point out that TAVR has revolutionized the treatment of aortic stenosis and is currently targeting less complex and young patients with lower surgical risk. Despite the relatively low incidence of IE after TAVR, the number of procedures is expected to grow exponentially, increasing the number of patients at risk of developing this life-threatening complication. Therefore, detailed knowledge of this disease and its complications is essential to improve the results.

They point out that the 10% stroke rate found in this study is substantially lower compared to surgical records of infectious endocarditis with larger prosthetic valve, but suggest that the unique clinical profile of patients with TAVR may lead to an underdiagnosis of stroke, with a high proportion of elderly patients more frequently presenting with nonspecific symptoms.

They conclude that “post-TAVR EI is associated with a poor prognosis with high in-hospital and late mortality rates. Our study reveals that patients with IE after TAVR complicated by stroke had an even worse prognosis.”

“The progressive implementation of advanced imaging modalities for the early diagnosis of IE, especially nuclear imaging, can translate into a better prognosis in the coming years. Much attention must be paid to the early recognition of the factors associated with stroke to improve clinical outcomes, ”they add.

In a accompanying editorial, Vuyisile Nkomo, MD, Daniel DeSimone, MD, and William Miranda, MD, Mayo Clinic, Rochester, Minnesota, say the current study “highlights the devastating consequences of IS after TAVR and the even worse consequences when IE was associated with stroke. “

This points to the critical importance of efforts to prevent IE with appropriate antibiotic prophylaxis and to address potential sources of infection (e.g., dental screening) before invasive cardiac procedures.

“Patient education is critical in recognizing early signs and symptoms of IE. In particular, patients should be informed to obtain blood cultures with any episode of fever, as identification of bacteremia is critical in diagnosis. of ISIS, ”comment the editorialists.

Endocarditis should also be suspected in afebrile patients with increasing gradients of transcatheter heart valve or new or worsening insufficiency, they claim.

They add that multimodal imaging is important for early diagnosis of EI to facilitate rapid antibiotic treatment and potentially decrease the risk of EI complications, especially systemic embolization.

“Despite unequivocal advances in the safety and periprocedural complications of TAVR, IS with and without stroke in this TAVR population remains a terrible complication,” they conclude.

Del Val received the support of a research grant from the Alfonso Martin Escudero Foundation (Madrid, Spain). The publishers have not revealed any relevant financial relationship.

J Am Coll Cardiol. Published online May 3, 2021. Summary, Editorial

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