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Vol. 72. Issue 5.
Pages 428-430 (May 2019)
Scientific letter
DOI: 10.1016/j.rec.2018.04.015
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Predictors of Sterile Aortic Valve Following Aortic Infective Endocarditis. Preliminary Analysis of Potential Candidates for TAVI
Predictores de esterilidad de la válvula aórtica tras endocarditis infecciosa aórtica. Análisis preliminar de potenciales candidatos para TAVI
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Pablo E. García-Granjaa, Ignacio J. Amat-Santosa,b,
Corresponding author
ijamat@gmail.com

Corresponding author:
, Isidre Vilacostac, Carmen Olmosc, Itziar Gómeza,b, J. Alberto San Román Calvara,b
a Servicio de Cardiología, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario, Valladolid, Spain
b CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
c Servicio de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
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Table 1. Univariable and Multivariable Predictors of Active Local Infection at the Time of Cardiac Surgery in Patients With Aortic Valve Infective Endocarditis
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To the Editor,

There are only a few anecdotic reports of aortic infective endocarditis (IE) treated with transcatheter aortic valve replacement (TAVR).1,2 Although dysfunction of a damaged valve can be treated with a TAVR device, persistent local infection requires debridement of the affected tissue and precludes the use of TAVR since reinfection would carry a dreadful prognosis.2 Thereafter, IE has been an exclusion criterion in most landmark studies and the use of TAVR in this context has been empirically disregarded. In contrast, it is well known that antibiotic treatment in IE is highly effective in some particular etiologies and, often, the only reason for cardiac surgery is the residual symptomatic severe valvular dysfunction.3 On this basis, TAVR might represent a novel alternative in this particular high operative risk subset if specific markers of healed infection could be determined.

The aim of this study was to identify the main predictors of active local infection at the time of intervention that would preclude TAVR use in IE. Among a total of 732 episodes of left-sided IE consecutively diagnosed in 2 tertiary centers between 1996 and 2015, 432 patients underwent cardiac surgery and 224 of them had involvement of either native or biological prosthetic aortic valves. Only patients with culture of the removed cardiac tissue (n = 182) were included. In addition, patients with discordant positive valve culture (n = 14) were excluded due to the impossibility of ruling out culture contamination.

We defined active local infection at the time of intervention as the presence of either periannular complications or concordant positive cultures (same microorganism in the blood and the cardiac tissue removed during surgery). Biological tissues were grown on brain heart broth and thioglycollate, and on 4 types of agar media (Columbia sheep blood, chocolate supplemented with IsoVitaleX, McKonkey, and Schaedler).

To determine predictors of active local infection at the time of intervention, we built a predictive model using a logistic regression model with the maximum likelihood method and backward stepwise selection, which included the variables that were clinically relevant and statistically significant in the univariable analysis. Only the last step is shown. The goodness-of-fit for each model was determined with the Hosmer–Lemershow test and the area under the receiver operating characteristics curve (AUC-ROC).

The Table summarizes the univariable and multivariable predictors of active local infection at the time of intervention. The main independent predictors of active local infection were diabetes mellitus (odds ratio [OR], 2.8; 95% confidence interval [95%CI], 1.1-7.4), Staphylococcus aureus (OR, 4.3; 95%CI, 1.4-13.4) and concomitant mitral involvement (OR, 2.5; 95%CI, 1.1-5.8). In contrast, an interval between diagnosis and intervention ≥ 10 days (estimated cut-off value) was a predictive factor of healed infection (OR, 0.25; 95%CI, 0.1-0.5). The model had an AUC-ROC of 0.776 (95%CI, 0.705-0.847) and a Hosmer–Lemershow P value of .848. Indeed, after 10 days of appropriate antibiotic treatment and in the absence of diabetes mellitus, Staphylococcus aureus, concomitant mitral involvement, or aortic prosthesis, only 1 patient out of 29 (3.5%) had a positive culture at the time of intervention.

Table 1.

Univariable and Multivariable Predictors of Active Local Infection at the Time of Cardiac Surgery in Patients With Aortic Valve Infective Endocarditis

Variables  Nonactive local
infection
(n = 79) 
Active local infection
(n = 89) 
Pa  OR  95%CI  Pa   
          Inferior  Superior   
Age, y  61.6 ± 14  63.4 ± 14.7  .434         
Male sex  64 (81)  69 (78)  .579         
Nosocomial originb  10 (13)  21 (24)  .068         
Heart disease  63 (80)  60 (67)  .072         
Degenerative  21 (27)  18 (20)  .330         
Prosthesis  11 (14)  26 (29)  .017  2.5  0.99  6.1  .054 
Rheumatic  3 (4)  0 (0)  .102         
Comorbiditiesc  36 (46)  47 (53)  .349         
Charlson index  3.3 ± 2.9  3.4 ± 2.3  .886         
Chronic renal failure  5 (6)  11 (12)  .184         
Diabetes mellitus  8 (10)  25 (28)  .003  2.8  1.1  7.4  .032 
Clinical progression
Heart failure  55 (70)  65 (74)  .543         
Renal failure  24 (30)  23 (26)  .543         
Septic shock  1 (1)  8 (9)  .036         
Stroke  11 (14)  9 (10)  .463         
Microbiology
Streptococci species  34 (43)  22 (25)  .012         
S. bovis  7 (9)  4 (5)  .253         
S. viridans  20 (25)  16 (18)  .247         
Enterococci species  12 (15)  12 (14)  .752         
Staphylococci species  15 (19)  40 (45)  < .001         
S. aureus  5 (6)  18 (20)  .009  4.3  1.4  13.4  .011 
Coagulase-negative Staphylococci  10 (13)  22 (25)  .047         
Echocardiographic findings
Vegetation  77 (98)  77 (87)  .010         
Significant valvular dysfunction  70 (89)  77 (87)  .683         
Concomitant mitral disease  14 (18)  30 (34)  .019  2.5  1.1  5.8  .027 
Outcomes
Urgent surgeryd  48 (61)  69 (78)  .018         
Elective surgerye  31 (39)  20 (22)           
Time from diagnosis to surgery, df  13.5 [6.5-27]  6 [2-12]  < .001  0.25  0.1  0.5  <.001 
Time from correct antibiotic beginning to surgery, d  17 [7-31]  8 [3-17]  < .001         
In-hospital mortality  12 (15)  22 (25)  .125         
Relapses  0 (0)  2 (2)  .499         

95%CI: 95% confidence interval; OR: odds ratio.

The data are expressed as mean ± standard deviation or median [interquartile range] or No. (%).

a

Significant P values in bold letters.

b

Nosocomial origin: signs and symptoms of infective endocarditis starting after 48hours from hospital admission or in the first 3 days after discharge or up to 30 days after a surgical intervention.

c

Comorbidities: defined by the presence of either diabetes mellitus, chronic renal failure, immunosuppression, chronic pulmonary disease, cancer, collagenopathy requiring steroids, HIV or intravenous drug use.

d

Urgent surgery: surgery performed during the active phase of infective endocarditis, before the end of the antibiotic treatment.

e

Elective surgery: surgery performed after the end of the antibiotic treatment.

f

For the multivariable analysis, we included time between diagnosis and surgery ≥ 10 days.

Recommendations against the use of TAVR in the context of uncomplicated aortic valve IE are based on unfounded but extensively accepted arguments. For the first time, we have evaluated the actual risk of this potential management in a large population of surgical patients whose resected tissue was cultured, demonstrating that most patients have a predictable lack of local infection after antibiotic therapy. This hypothesis-generating finding might support the use of TAVR in selected cases of IE with “healed” infection but residual lesion and high surgical risk. Conversely, periannular complications, the need for extensive surgical repair, septic shock, and infection of biological prosthesis might be related to persistent infection, suggesting that TAVR should be also avoided in these scenarios until further data are available.4,5

In conclusion, our findings suggest that in poor surgical candidates and under the assessment of a multidisciplinary experienced IE team, TAVR could be considered as an alternative therapeutic option in selected cases of IE with low risk of local infection at the time of the planned intervention.

.

References
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C. Albu, M.J. Swaans, J.M. ten Berg.
With the back against the wall: TAVI in a patient with endocarditis.
Catheter Cardiovasc Interv., 82 (2013), pp. E595-E597
[2]
K. Pechlivanidis, F. Onorati, G. Petrilli, et al.
In which patients is transcatheter aortic valve replacement potentially better indicated than surgery for redo aortic valve disease? Long-term results of a 10-year surgical experience.
J Thorac Cardiovasc Surg., 148 (2014), pp. 500-508
[3]
P. Tornos, B. Iung, G. Permanyer-Miralda, et al.
Infective endocarditis in Europe: lessons from the Euro heart survey.
Heart., 91 (2005), pp. 571-575
[4]
C. Knosalla, Y. Weng, A.C. Yankah, et al.
Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess—11 year results.
Eur Heart J., 21 (2000), pp. 490-497
[5]
C. Graupner, I. Vilacosta, J. San Roman, et al.
Periannular extension of infective endocarditis.
J Am Coll Cardiol., 39 (2002), pp. 1204-1211
Copyright © 2018. Sociedad Española de Cardiología
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