Early Prosthetic Valve Endocarditis Complicating Repeated Attempts at CoreValve Implantation

ABSTRACT: Transcatheter aortic valve implantation is emerging as a promising, effective therapy for high-risk patients not eligible to undergo surgical aortic valve replacement. Infection complications have only rarely been reported. We report a case of probable endocarditis caused by coagulase-negative Staphylococcus following repeated attempts at implantation of a CoreValve bioprosthesis.

J INVASIVE CARDIOL 2011;23(12):E291-E292

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Transcatheter aortic valve implantation (TAVI) is a novel procedure for the management of patients with severe symptomatic aortic stenosis at high operative risk for traditional surgical replacement. Infectious complications have only rarely been reported.

Case Report. An 84-year-old male with history of severe symptomatic aortic stenosis (valve area, 0.7 cm²; mean transvalvular gradient, 64 mm Hg) was referred for TAVI. The annulus was measured at 25-26.5 mm by transesophageal echocardiography. Coronary angiography was unremarkable and iliofemoral angiography was favorable for transfemoral TAVI. Comorbidities included previous cerebrovascular disease, atrial fibrillation, chronic lung disease, chronic pancreatitis, and prior pacemaker implantation. The logistic Euroscore was estimated at 23.5%.

Transfemoral TAVI was performed in the catheterization laboratory under monitored anesthesia care with use of the 29 mm CoreValve bioprosthesis. The combination of vancomycin and ciprofloxacin were administered perioperatively. During the first two attempts at valve deployment, the valve moved above the left coronary leaflet; for this reason, it was withdrawn twice, retracted out of the sheath and recrimped (Figures 1A-1C). The third attempt at deployment was successful (Figures 1D-1F). Postprocedure imaging revealed mild to moderate paravalvular regurgitation.

Echocardiography 4 weeks after TAVI revealed stable paravalvular regurgitation with normal functioning prosthesis (Figures 2A-2B). At approximately 80 days postimplantation, the patient was admitted for sepsis and Staphylococcus epidermidis was isolated on 3 separate blood cultures. Inflammatory indexes of ESR and CRP were elevated. Transesophageal echocardiography revealed no clear evidence of vegetation on the bioprosthesis. The patient was treated empirically for probable early prosthetic valve endocarditis with intravenous antibiotics for 4 weeks. The blood cultures became serially negative and the indexes of inflammation returned to normal. At 12-month follow-up, the patient was doing well.

Discussion. TAVI is emerging as a promising, effective therapy for high-risk patients who are ineligible to undergo surgical aortic valve replacement.¹ Reported rates of endocarditis in published series were in the order of 1.1%.^2,3 We report a case of probable endocarditis caused by coagulase-negative Staphylococcus following repeated attempts at implantation of a CoreValve bioprosthesis. The time course resembles what has been described in the surgical literature as early prosthetic valve endocarditis with symptom onset <60 days from valve deployment. Commonly, these infections are caused by staphylococcal species (i.e., Staphylococcus aureus, coagulase-negative staphylococcal species) and less likely they may be culture negative or due to fungal species.⁴ These infections are attributed to contamination intra-operatively or to bacteremia that occurred in the initial days and weeks after surgery.

Three other case reports^5-7 of TAVI endocarditis have been published involving both types of commercially available valves. Offending bacteria included Enterococcus faecalis, Corynebacterium and Streptococcus anginosus. Presentation was 3 to 11 months postimplantation. In two of these cases, endocarditis manifested with involvement not only of the prosthetic aortic valve but also with development of perforation and aneurysm of the anterior mitral valve leaflet. 

Endocarditis prophylaxis regimens for TAVI have been left to institutional preference. Extrapolating from the surgical literature and most recent guidelines,⁸ prophylaxis at the time of TAVI should be directed primarily against staphylococci. A first-generation cephalosporin is mostly recommended. In institutions with a high rate of methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis infections, a vancomycin regimen can be chosen instead. Prophylaxis should be initiated immediately before the procedure and maintained for no more than 48 hours to decrease the risk of emergence of resistant strains. Strict sterile precautions should be employed. Endocarditis prophylaxis prior to future dental or other procedures is also advisable.

We believe an important risk factor for the development of TAVI endocarditis unique to the CoreValve system is the potential for recurrent attempts at valve deployment that require the valve to be handled multiple times for crimping purposes. 

In summary, we present a case of probable endocarditis complicating the deployment of a CoreValve bioprosthesis with successul resolution after antibiotic therapy without long-term sequealae.

References

1. Thomas M. The global experience with percutaneous aortic valve replacement. JACC Cardiovasc Interv. 2010;3(11):1103-1109.
2. Leon M, Smith C, Mack M, et al. Transcatheter aortic valve implantation for  aortic stenosis in patients who cannot undergo surgery. N Engl J Med.  2010;363(17):1597-1607.
3. Gurvich R, Wood DA, Tay EL, et al. Transcatheter aortic valve implantation. Circulation. 2010;122(13):1319-1327.
4. Wang A, Athan E, Pappas PA, et al; International Collaboration on Endocarditis-Prospective Cohort Study Investigators. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA. 2007;297(12):1354-1361. 
5. Carnero-Alcázar M, Maroto Castellanos LC, Carnicer JC, Rodríguez Hernández JE. Transapical aortic valve prosthetic endocarditis. Interact Cardiovasc Thorac Surg. 2010;11(3):252-253.
6. Comoglio C, Boffini M, El Qarra S, et al. Aortic valve replacement and mitral valve repair as treatment of complications after percutaneous CoreValve implantation. J Thorac Cardiovasc Surg. 2009;138(4):1025-1027.
7. Wong DR, Boone RH, Thompson CR, et al. Mitral valve injury late after transcatheter aortic valve implantation. J Thorac Cardiovasc Surg. 2009;137(6):1547-1549.
8. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-1754.

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From the ¹Department of Transcatheter Heart Valves, Hygeia Hospital, Athens, Greece, and ²Central Clinic of Athens, Athens, Greece.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Spargias is a proctor for Edwards Lifesciences. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted April 19, 2011, provisional acceptance given June 27, 2011, final version accepted July 12, 2011.
Address for correspondence: Michael P. Chrissoheris, MD, 4 Erithrou Stavrou Street and Kifissias Avenue, 15123 Marousi, Athens, Greece.  Email:  mchrissoheris@hotmail.com