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Original Investigation |

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

Ander Regueiro, MD1; Axel Linke, MD2; Azeem Latib, MD3; 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.
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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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Figure 1.
Flowchart of the Study Cohort

aPatients from the individual data cohort were selected among 31 centers that provided individual data. The 108 patients with definite infective endocarditis after transcatheter aortic valve replacement (TAVR) who were included in the Individual Data Cohort were also part of the Global Study Cohort.

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Figure 2.
Survival Curve for Patients With Infective Endocarditis After Transcatheter Aortic Valve Replacement in the Global Study Cohort

Kaplan-Meier survival curve during the 24-month follow-up after infective endocarditis following transcatheter aortic valve replacement. Median follow-up of 10.5 months (interquartile range, 3-21 months). Follow-up time was not available for 3 patients.

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