Catheterization and Cardiovascular Interventions 00:00–00 (2014)
Case Report Infective Endocarditis as a Mid-Term Complication After Transcatheter Aortic Valve Implantation: Case Report and Literature Review ek, MD, and Hana Lınkova , MD enko,* MD, Petr Tous Jakub Sulz Few cases of infective endocarditis (IE) as a complication of percutaneous transcatheter aortic valve implantation (TAVI) have been reported. Here, we present a case of IE caused by Streptococcus viridans that occurred 6 months after TAVI with the corevalve revalving system. The patient was successfully treated with antibiotics and was asymptomatic during the 2 years after IE. We also present a review of the literature, including 15 published cases of IE after TAVI. VC 2014 Wiley Periodicals, Inc. Key words: transcatheter aortic valve implantation; infective endocarditis; follow-up
INTRODUCTION
Transcatheter aortic valve implantation (TAVI), introduced in 2002, is a method for the treatment of patients with aortic stenosis and high surgical risk or who are contraindicated for surgical valve replacement. Mid-term results of this method are promising, but not without complications, which are usually periprocedural. Few cases of infective endocarditis (IE) as a complication of TAVI have been reported. The following clinical case report describes a patient with IE caused by Streptococcus viridans that occurred 6 months after TAVI at our center.
Echocardiography before discharge confirmed good function of the aortic prosthesis with favorable hemodynamic characteristics and mild paravalvular regurgitation. No pathology was observed during the first month after implantation, and laboratory tests were within physiological limits. At his 6-month follow-up visit, the patient complained of a lack of appetite, dyspepsia, and episodes of fever and chills during the last 3 months. He had lost 10–15 kg in body weight since the last visit. Transthoracic echocardiography revealed an unclear finding on the aortic root, which was suspected to be a vegetation on the leaflets of the prosthesis. The patient was hospitalized immediately. Laboratory tests
CASE REPORT
An 84-year-old male was indicated for TAVI by our heart team due to a high surgical risk with a EuroScore of 30%. Furthermore, the patient had a history of aortocoronary bypass 7 years before TAVI that was complicated by mediastinitis with the need for plastic surgical closure of a defect after a sternotomy. A left-side subclavian approach was chosen because of inappropriate anatomy of the femoral arteries affected by atherosclerosis. After balloon valvuloplasty, a 29-mm corevalve revalving system (Medtronic Cardiovascular, Santa Rosa, CA) was implanted successfully. No complications or conduction abnormalities occurred, and the patient was discharged after 8 days. C 2014 Wiley Periodicals, Inc. V
Cardiocenter University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic Contract grant sponsor: University Research Project; Contract grant number: UNCE-204010. *Correspondence to: Jakub Sulzenko MD, III. Internal – Cardiology department, pavilon S, University Hospital Kralovske Vinohrady, arova 1150/50, Prague 10, 100 34, Czech Republic. Srob E-mail: [email protected] Received 16 September 2013; Revision accepted 16 February 2014 DOI: 10.1002/ccd.25454 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
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showed leukocytosis with a predominance of neutrophils, and an elevated C-reactive protein level (>52.6 mg/L). Multiple hemoculture samples were taken, and transesophageal echocardiography (TEE) was performed. TEE demonstrated mobile vegetations (12 6 and 2 5 mm) on the leaflets of the aortic prosthesis (Fig. 1). The hemocultures were positive, and dual
intravenous antibiotic therapy with ampicillin and gentamicin was started. Cultivation of the hemocultures confirmed S. viridans as the etiological agent. Based on an examination of the minimum inhibitory concentration, the antibiotic was changed to vancomycin monotherapy. Gentamicin was added, but vancomycin was changed to penicillin-G because of poor renal
Fig. 1. Transesophageal echocardiogram (mid-esophageal long-axis ascending aorta view) with a large vegetation on the prosthetic valve cuspid. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 2. Calcium scoring by native CT of a prosthetic valve with a small calcification (probably old calcified vegetations) (long-axis view of the prosthesis).
Fig. 3. Calcium scoring by native CT of a prosthetic valve with small calcifications (probably old calcified vegetations) (shortaxis view of the prosthesis).
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Infective endocarditis after TAVI
3
TABLE I. Summary of Etiology and Treatment Strategy of Known TAVI Endocarditis Cases Case number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Etiological agent
Time from implantation to TAVE diagnosis
Treatment
Surviving
Corynebacterium Streptococcus anginosus Enterococcus faecalis Histoplasma capsulatum Moraxella nonliquefaciens Staphylococcus lugdunensis S. epidermidis S. aureus E. faecium unknown MRSA E. faecalis E. faecalis E. coli S. gordonii
4 moths 6 months 3 months 9 months 2 months 19 months 3 months 4 months 4 months 12 months 7 months 3 months 9 months 5 months 23 months
Surgical Surgical Antibiotic Surgical Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Surgical Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic
þ þ þ þ þ þ þ þ þ þ þ
function after 20 days of therapy. An abdominal sonogram was negative. TEE performed 3 weeks after admission showed significantly regressed residual vegetation (7 3 mm). Aortic prosthesis function was not impaired, but two mild paravalvular leak jets were found. The patient was discharged after 50 days of hospitalization following multiple negative inflammatory marker tests and hemocultures. Follow-up examinations 1 and 2 years after implantation confirmed good function of the aortic prosthesis with favorable hemodynamic characteristics, mild paravalvular regurgitation, and one mild transvalvular regurgitation jet. The patient has remained clinically asymptomatic (Figs. 2,3). DISCUSSION
IE is a rare but severe complication of TAVI. Prosthetic valve endocarditis (PVE) due to implantation of a surgical prosthesis occurs at a rate of 0.3–1% per patient-year and accounts for 1–5% of all IE cases [1–5]. The incidence in TAVI-treated patients according to recently published mid- and longer-term trials is thought to be very low [6,7]. In the randomized PARTNER trial, the incidence of TAVI endocarditis was 0.6% at 1 year and 1.5% at 2 years after treatment, respectively [8]. To our knowledge, 15 cases of transcatheter implanted IE have been published to date (Table I). The first two cases were associated with an aneurysm and perforation of the anterior mitral valve leaflet [9]. The first was caused by Corynebacterium 4 months after TAVI [10], whereas the second case was caused by S. anginosus 6 months after implantation and 6 weeks after a dental visit with a lack of endocarditis prophylaxis. In both cases, the prosthesis was
implanted too low and was in contact with the anterior mitral valve leaflet. This caused an aneurysm in the anterior mitral valve leaflet at the site of contact between the ventricular edges of the infected prosthesis. The third case was caused by Enterococcus faecalis 3 months after TAVI in a patient with a urinary tract infection, which was the most probable origin of the endocarditis [11]. The fourth case was caused by Histoplasma capsulatum 9 months after TAVI [12], and the fifth case was caused by Moraxella nonliquefaciens 2 months after implantation [13]. The sixth case was caused by Staphylococcus lugdunensis 19 months after TAVI, but 4 weeks after percutaneous coronary intervention without endocarditis prophylaxis [14]. The seventh case of early PVE was complicated by repeated attempts at implantation and was caused by S. epidermidis [15]. The next case was caused by methicillin-sensitive S. aureus 4 months after implantation and 2 months after a colonoscopy was conducted without endocarditis prophylaxis [16]. Another case of an 85-year-old male with TAVI PVE was successfully treated medically, as described by Loh et al. [17]. The next case occurred 1 year after implantation in a patient with Osler–Weber–Rendu syndrome after odontoiatric treatment without antibiotic prophylaxis 2 months earlier [18]. A lack of antibiotic prophylaxis during odontoiatric treatment was also described in the second reported case of TAVI PVE occurring 11 months after implantation [19]. Another five cases of IE were described in a single-center report (an estimated PVE incidence 3.4% at 1 year) [20]. Four of these patients died, four were successfully treated surgically, and seven were successfully treated with antibiotics without surgery. The large number of
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
4
enko et al. Sulz
primary nonsurgical patients treated surgically is unexpected. However, most of these patients were described as high risk for surgery, but not as contraindicated for surgery even before TAVI. Their average EuroScore was low, but they suffered several comorbidities, which led to the decision to perform TAVI. Surgical treatment has to be indicated individually, especially in this population of high-risk patients, usually due to severe progressive heart failure, perivalvular extension of IE, or a high risk of systemic embolism [21]. The risk among patients treated surgically with TAVI PVE is unknown, but is believed to be very high according to data from trials describing emergent cardiac surgery during TAVI [22]. According to these cases, PVE is a severe complication, and adequate prophylaxis of IE among patients with TAVI should always be considered before invasive procedures. According to studies of surgical prostheses, staphylococci, fungi, and Gram-negative bacilli are the main causes of early (
Case Report Infective Endocarditis as a Mid-Term Complication After Transcatheter Aortic Valve Implantation: Case Report and Literature Review ek, MD, and Hana Lınkova , MD enko,* MD, Petr Tous Jakub Sulz Few cases of infective endocarditis (IE) as a complication of percutaneous transcatheter aortic valve implantation (TAVI) have been reported. Here, we present a case of IE caused by Streptococcus viridans that occurred 6 months after TAVI with the corevalve revalving system. The patient was successfully treated with antibiotics and was asymptomatic during the 2 years after IE. We also present a review of the literature, including 15 published cases of IE after TAVI. VC 2014 Wiley Periodicals, Inc. Key words: transcatheter aortic valve implantation; infective endocarditis; follow-up
INTRODUCTION
Transcatheter aortic valve implantation (TAVI), introduced in 2002, is a method for the treatment of patients with aortic stenosis and high surgical risk or who are contraindicated for surgical valve replacement. Mid-term results of this method are promising, but not without complications, which are usually periprocedural. Few cases of infective endocarditis (IE) as a complication of TAVI have been reported. The following clinical case report describes a patient with IE caused by Streptococcus viridans that occurred 6 months after TAVI at our center.
Echocardiography before discharge confirmed good function of the aortic prosthesis with favorable hemodynamic characteristics and mild paravalvular regurgitation. No pathology was observed during the first month after implantation, and laboratory tests were within physiological limits. At his 6-month follow-up visit, the patient complained of a lack of appetite, dyspepsia, and episodes of fever and chills during the last 3 months. He had lost 10–15 kg in body weight since the last visit. Transthoracic echocardiography revealed an unclear finding on the aortic root, which was suspected to be a vegetation on the leaflets of the prosthesis. The patient was hospitalized immediately. Laboratory tests
CASE REPORT
An 84-year-old male was indicated for TAVI by our heart team due to a high surgical risk with a EuroScore of 30%. Furthermore, the patient had a history of aortocoronary bypass 7 years before TAVI that was complicated by mediastinitis with the need for plastic surgical closure of a defect after a sternotomy. A left-side subclavian approach was chosen because of inappropriate anatomy of the femoral arteries affected by atherosclerosis. After balloon valvuloplasty, a 29-mm corevalve revalving system (Medtronic Cardiovascular, Santa Rosa, CA) was implanted successfully. No complications or conduction abnormalities occurred, and the patient was discharged after 8 days. C 2014 Wiley Periodicals, Inc. V
Cardiocenter University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic Contract grant sponsor: University Research Project; Contract grant number: UNCE-204010. *Correspondence to: Jakub Sulzenko MD, III. Internal – Cardiology department, pavilon S, University Hospital Kralovske Vinohrady, arova 1150/50, Prague 10, 100 34, Czech Republic. Srob E-mail: [email protected] Received 16 September 2013; Revision accepted 16 February 2014 DOI: 10.1002/ccd.25454 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
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enko et al. Sulz
showed leukocytosis with a predominance of neutrophils, and an elevated C-reactive protein level (>52.6 mg/L). Multiple hemoculture samples were taken, and transesophageal echocardiography (TEE) was performed. TEE demonstrated mobile vegetations (12 6 and 2 5 mm) on the leaflets of the aortic prosthesis (Fig. 1). The hemocultures were positive, and dual
intravenous antibiotic therapy with ampicillin and gentamicin was started. Cultivation of the hemocultures confirmed S. viridans as the etiological agent. Based on an examination of the minimum inhibitory concentration, the antibiotic was changed to vancomycin monotherapy. Gentamicin was added, but vancomycin was changed to penicillin-G because of poor renal
Fig. 1. Transesophageal echocardiogram (mid-esophageal long-axis ascending aorta view) with a large vegetation on the prosthetic valve cuspid. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 2. Calcium scoring by native CT of a prosthetic valve with a small calcification (probably old calcified vegetations) (long-axis view of the prosthesis).
Fig. 3. Calcium scoring by native CT of a prosthetic valve with small calcifications (probably old calcified vegetations) (shortaxis view of the prosthesis).
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Infective endocarditis after TAVI
3
TABLE I. Summary of Etiology and Treatment Strategy of Known TAVI Endocarditis Cases Case number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Etiological agent
Time from implantation to TAVE diagnosis
Treatment
Surviving
Corynebacterium Streptococcus anginosus Enterococcus faecalis Histoplasma capsulatum Moraxella nonliquefaciens Staphylococcus lugdunensis S. epidermidis S. aureus E. faecium unknown MRSA E. faecalis E. faecalis E. coli S. gordonii
4 moths 6 months 3 months 9 months 2 months 19 months 3 months 4 months 4 months 12 months 7 months 3 months 9 months 5 months 23 months
Surgical Surgical Antibiotic Surgical Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic Surgical Antibiotic Antibiotic Antibiotic Antibiotic Antibiotic
þ þ þ þ þ þ þ þ þ þ þ
function after 20 days of therapy. An abdominal sonogram was negative. TEE performed 3 weeks after admission showed significantly regressed residual vegetation (7 3 mm). Aortic prosthesis function was not impaired, but two mild paravalvular leak jets were found. The patient was discharged after 50 days of hospitalization following multiple negative inflammatory marker tests and hemocultures. Follow-up examinations 1 and 2 years after implantation confirmed good function of the aortic prosthesis with favorable hemodynamic characteristics, mild paravalvular regurgitation, and one mild transvalvular regurgitation jet. The patient has remained clinically asymptomatic (Figs. 2,3). DISCUSSION
IE is a rare but severe complication of TAVI. Prosthetic valve endocarditis (PVE) due to implantation of a surgical prosthesis occurs at a rate of 0.3–1% per patient-year and accounts for 1–5% of all IE cases [1–5]. The incidence in TAVI-treated patients according to recently published mid- and longer-term trials is thought to be very low [6,7]. In the randomized PARTNER trial, the incidence of TAVI endocarditis was 0.6% at 1 year and 1.5% at 2 years after treatment, respectively [8]. To our knowledge, 15 cases of transcatheter implanted IE have been published to date (Table I). The first two cases were associated with an aneurysm and perforation of the anterior mitral valve leaflet [9]. The first was caused by Corynebacterium 4 months after TAVI [10], whereas the second case was caused by S. anginosus 6 months after implantation and 6 weeks after a dental visit with a lack of endocarditis prophylaxis. In both cases, the prosthesis was
implanted too low and was in contact with the anterior mitral valve leaflet. This caused an aneurysm in the anterior mitral valve leaflet at the site of contact between the ventricular edges of the infected prosthesis. The third case was caused by Enterococcus faecalis 3 months after TAVI in a patient with a urinary tract infection, which was the most probable origin of the endocarditis [11]. The fourth case was caused by Histoplasma capsulatum 9 months after TAVI [12], and the fifth case was caused by Moraxella nonliquefaciens 2 months after implantation [13]. The sixth case was caused by Staphylococcus lugdunensis 19 months after TAVI, but 4 weeks after percutaneous coronary intervention without endocarditis prophylaxis [14]. The seventh case of early PVE was complicated by repeated attempts at implantation and was caused by S. epidermidis [15]. The next case was caused by methicillin-sensitive S. aureus 4 months after implantation and 2 months after a colonoscopy was conducted without endocarditis prophylaxis [16]. Another case of an 85-year-old male with TAVI PVE was successfully treated medically, as described by Loh et al. [17]. The next case occurred 1 year after implantation in a patient with Osler–Weber–Rendu syndrome after odontoiatric treatment without antibiotic prophylaxis 2 months earlier [18]. A lack of antibiotic prophylaxis during odontoiatric treatment was also described in the second reported case of TAVI PVE occurring 11 months after implantation [19]. Another five cases of IE were described in a single-center report (an estimated PVE incidence 3.4% at 1 year) [20]. Four of these patients died, four were successfully treated surgically, and seven were successfully treated with antibiotics without surgery. The large number of
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
4
enko et al. Sulz
primary nonsurgical patients treated surgically is unexpected. However, most of these patients were described as high risk for surgery, but not as contraindicated for surgery even before TAVI. Their average EuroScore was low, but they suffered several comorbidities, which led to the decision to perform TAVI. Surgical treatment has to be indicated individually, especially in this population of high-risk patients, usually due to severe progressive heart failure, perivalvular extension of IE, or a high risk of systemic embolism [21]. The risk among patients treated surgically with TAVI PVE is unknown, but is believed to be very high according to data from trials describing emergent cardiac surgery during TAVI [22]. According to these cases, PVE is a severe complication, and adequate prophylaxis of IE among patients with TAVI should always be considered before invasive procedures. According to studies of surgical prostheses, staphylococci, fungi, and Gram-negative bacilli are the main causes of early (
