Fukuhara Shinichi, Suzuki Taichi, Deeb G Michael, Ailawadi Gorav, Patel Himanshu J, Yang Bo, El-Dalati Sami
Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.
Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA.
Ann Cardiothorac Surg. 2025 Mar 31;14(2):141-150. doi: 10.21037/acs-2024-etavr-0103. Epub 2024 Nov 12.
Prosthetic valve endocarditis is a rare yet devastating complication following transcatheter aortic valve replacement (TAVR). This study aims to investigate the outcomes of surgical versus medical management of post-TAVR endocarditis.
Between 2011 and 2024, 67 patients with post-TAVR endocarditis were identified, comprising 24 (35.8%) patients managed surgically and 43 (64.2%) managed medically. All cases were reviewed by our multidisciplinary endocarditis team to determine the optimal treatment strategy.
The overall incidence of post-TAVR endocarditis was 1.4%. The number of endocarditis cases increased over time from 1-2 in 2015-2018 to 18 in 2023. The most frequent source of endocarditis was unknown (32.8%), and the predominant causative organism was enterococcus species (25.4%). Notably, among the 43 medically managed patients, 19 (44.2%) exhibited surgical indications, predominantly due to large vegetations with or without embolic complications (n=11; 57.9%). The medical management group had a higher proportion of females and more frequent use of self-expandable valves compared to the surgical group. The time interval between TAVR and endocarditis diagnosis was similar across both groups. In the surgically managed cohort, isolated aortic valve replacement was uncommon, with most patients undergoing complex TAVR explantations coupled with concomitant procedures, most frequently aortic root repair (n=11; 45.8%). The 30-day and 1-year mortality rates for the three groups (surgical, medical without surgical indications, and medical with surgical indications) were 0%, 4.2%, and 31.6% (P=0.002), and 4.2%, 20.8%, and 73.7% (P<0.001), respectively.
Surgical management was associated with significantly improved survival compared to medical management for post-TAVR endocarditis. The poor clinical outcomes in the medically managed group were primarily due to patients who did not undergo surgery despite having surgical indications. Prudent clinical judgment and timely surgical intervention when indicated are critical to enhancing the overall clinical outcomes of this challenging condition.
人工瓣膜心内膜炎是经导管主动脉瓣置换术（TAVR）后一种罕见但具有破坏性的并发症。本研究旨在探讨TAVR术后心内膜炎手术治疗与药物治疗的效果。
在2011年至2024年期间，共确定了67例TAVR术后心内膜炎患者，其中24例（35.8%）接受了手术治疗，43例（64.2%）接受了药物治疗。所有病例均由我们的多学科心内膜炎团队进行评估，以确定最佳治疗策略。
TAVR术后心内膜炎的总体发生率为1.4%。心内膜炎病例数随时间增加，从2015 - 2018年的1 - 2例增加到2023年的18例。最常见的心内膜炎来源不明（32.8%），主要致病微生物是肠球菌属（25.4%）。值得注意的是，在43例接受药物治疗的患者中，19例（44.2%）出现了手术指征，主要原因是存在大的赘生物伴或不伴有栓塞并发症（n = 11；57.9%）。与手术组相比，药物治疗组女性比例更高，且更频繁使用自膨胀瓣膜。两组TAVR与心内膜炎诊断之间的时间间隔相似。在接受手术治疗的队列中，单纯主动脉瓣置换并不常见，大多数患者接受了复杂的TAVR瓣膜取出术并伴有其他相关手术，最常见的是主动脉根部修复（n = 11；45.8%）。三组（手术组、无手术指征的药物治疗组和有手术指征的药物治疗组）的30天和1年死亡率分别为0%、4.2%和31.6%（P = 0.002），以及4.2%、20.8%和73.7%（P < 0.001）。
与TAVR术后心内膜炎的药物治疗相比，手术治疗与生存率显著提高相关。药物治疗组临床结局较差主要是由于尽管有手术指征但未接受手术的患者。谨慎的临床判断和在有指征时及时进行手术干预对于改善这种具有挑战性疾病的总体临床结局至关重要。
