Transcatheter aortic valve replacement associated infective endocarditis case series: broadening the criteria for diagnosis is the need of the hour

• Published in: BMC cardiovascular disorders 2021-11, Vol.21 (1), p.559-9, Article 559
• Main Authors: Lnu, Kriti, Ansari, Shamim, Mahto, Shantanu, Gada, Hemal, Mumtaz, Mubashir, Loran, David, Theckumparapil, Nikhil J, Vora, Amit N
• Format: Article
• Language: English
• Subjects: Abdomen; Abscesses; Aged; Anti-Bacterial Agents - therapeutic use; Antibiotics; Aortic valve; Aortic Valve - diagnostic imaging; Aortic Valve - surgery; Aortic valve stenosis; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - surgery; Bacteremia; Blood; Care and treatment; Case Report; Case studies; Complications; Complications and side effects; Computed tomography; Congestive heart failure; Device Removal; Diagnosis; Echocardiography; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Edema; Electrocardiography; Endocarditis; Endocarditis, Bacterial - diagnostic imaging; Endocarditis, Bacterial - microbiology; Endocarditis, Bacterial - therapy; Extracorporeal membrane oxygenation; Heart rate; Heart Valve Prosthesis - adverse effects; Heart valve replacement; Humans; Implants; Infective endocarditis; Inflammation; Intravenous administration; Literature reviews; Male; Medical imaging; Metabolism; Multi-modal imagining; Multimodal Imaging; Outpatient care facilities; Patients; Positron emission tomography; Positron Emission Tomography Computed Tomography; Predictive Value of Tests; Prostheses; Prosthesis-Related Infections - diagnostic imaging; Prosthesis-Related Infections - microbiology; Prosthesis-Related Infections - therapy; Prosthetic valve endocarditis; Reoperation; Reproducibility of Results; Risk factors; Sepsis; Stenosis; Surgery; TAVR; Transcatheter aortic valve replacement; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - instrumentation; Treatment Outcome; Ultrasonic imaging; Vegetation
• ISSN: 1471-2261; 1471-2261
• DOI: 10.1186/s12872-021-02364-0

Transcatheter valve replacement (TAVR) is an important therapeutic intervention for patients with aortic valve stenosis. As TAVR has become available to a broader population, there has been an increase in the number of less common, yet potentially catastrophic, complications. TAVR related infective endocarditis (TAVR-IE) is a rare, but potentially fatal, complication. We present here two patients that we encountered for TAVR associated infective endocarditis. Our first patient presented 5 weeks after his TAVR. His initial presentation was consistent with signs of sepsis. The patient then developed Mobitz type I block during hospital course. His TEE was negative for features of infective endocarditis. Due to high suspicion, patient was taken for surgical exploration and was found to have multiple foci of vegetation adhered to the stent frame. Our second patient presented with new onset pulmonary edema, worsening heart failure and systemic inflammatory response. A TEE was done for persistent MSSA bacteremia which showed stable prosthetic valve function with no signs of infective endocarditis. Patient was discharged with a prolonged course of intravenous antibiotics. Patient was re-admitted for worsening sepsis and blood cultures were positive for MSSA. Patient was taken for surgical exploration of his prosthetic aortic valve which showed purulent aortic root abscess. Through these cases, we aim to raise awareness on TAVR-IE. Due to the atypical clinical presentation, the modified Duke criteria may not be sufficient to diagnose TAVR-IE. Transesophageal echocardiogram in TAVR-IE may be negative or indeterminate. Prosthetic valve shadow may obscure smaller vegetations and/or smaller abscesses. A negative transesophageal echocardiogram should not rule out TAVR-IE and further diagnostic imaging modalities should be considered. PET/CT after administration of 18F-FDG (fluorodeoxyglucose) is a useful diagnostic tool in the diagnosis of infective endocarditis where TEE has been negative or inconclusive. Multi-modal imaging, in addition to the modified Duke criteria, can facilitate early diagnosis and improved mortality outcomes.