Infection et TAVI

Since trans-catheter valve implantation (TAVI) has emerged for severe symptomatic aortic stenosis treatment, infective endocarditis (IE) appears as a rare but severe complication. Like surgical aortic valve remplacement infective endocarditis (SAVR-IE), TAVI-IE has a noxious impact on morbidity and mortality. Compared to SAVR-IE, TAVI-IE present some similarities as well as differences. Most TAVI-IE occurred during the first year and enterococcus is the more common pathogen. A multimodality imaging approach including echocardiography, multislice computed tomography (CT) and positron emission tomography-CT with blood culture is necessary for the diagnosis. In this high-risk population, the vast majority of TAVI-IE patients are treated with antibiotic therapy alone. Consequently to the expanded indication, the increasing number of TAVI-IE will appear more frequently. If initially only few clinical cases of IE were reported, sparse observational multicenter registries have now been published. Relevant differences were noted on these registries, but some recent publications have provided new informations on IE. The present review reports incidence, symptoms, microbiological profil, risk factors and clinicals outcomes of TAVI-IE. Eventually, we describe the management and the treatment of IE in the context of TAVI.     

Fungal endocarditis after transfemoral aortic valve implantation

Transcatheter aortic valve implantation (TAVI) was introduced in 2006 as an alternative for surgical aortic valve replacement (SAVR) as treatment for patients with aortic stenosis. Endocarditis after TAVI has been anecdotally reported, but concerns aroused because SAVR is often needed to explant the endocarditic valve in a high risk patient previously deemed not to be a surgical candidate. We report a case of a patient who underwent TAVI because he was too high risk to undergo SAVR. Several months later, he developed an intermittent self‐limiting fever of unknown origin which eventually was diagnosed as endocarditis. The valve was surgically removed, and pathology showed an infection caused by Histoplasma capsulatum. The patient recovered fully and remains in good condition.© 2011 Wiley Periodicals, Inc.     

Infective endocarditis as a mid‐term complication after transcatheter aortic valve implantation

Few cases of infective endocarditis (IE) as a complication of percutaneous transcatheter aortic valve implantation (TAVI) have been reported. Here, we present a case of IE caused by Streptococcus viridans that occurred 6 months after TAVI with the corevalve revalving system. The patient was successfully treated with antibiotics and was asymptomatic during the 2 years after IE. We also present a review of the literature, including 15 published cases of IE after TAVI. © 2014 Wiley Periodicals, Inc.     

Infective Endocarditis After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review

Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR procedure (less invasive) and its expansion to younger and healthier patients, the incidence of IE after TAVR remains stable, with incidence rates similar to those reported after surgical aortic valve replacement. Although IE after TAVR is recognized as a subtype of prosthetic valve endocarditis, this condition represents a particularly challenging scenario given its unique clinical and microbiological profile, the high incidence of IE-related complications, the uncertain role of cardiac surgery, and the dismal prognosis in most patients with TAVR-IE. The number of TAVR procedures is expected to grow exponentially in the coming years, increasing the number of patients at risk of developing this life-threatening complication. Therefore, a detailed understanding of this disease and its complications will be essential to improve clinical outcomes.     

Transcatheter aortic valve implantation in patient with cardiogenic shock

Transcatheter aortic valve implantation (TAVI) is an established treatment option in patients with symptomatic severe aortic stenosis, who are at high or intermediate risk for surgical aortic valve replacement. The vast majority of TAVI are performed on patients without acute decompensated heart failure. In this case report we present the successful TAVI in a patient with a cardiogenic shock.     

Challenging TAVI imaging case with Portico valve

Transcatheter aortic valve implantation is considered as an appropriate alternative to surgical valve replacement in patients with severe symptomatic aortic valve stenosis at moderate to high perioperative risk. There have also been case reports and patient series using TAVI system in patients with predominant or pure symptomatic aortic regurgitation. We report a case of a patient with symptomatic combined aortic valve disease that was successfully treated with selfexpandable Portico system despite extremely elliptical annulus.     

Infective Endocarditis in the Transcatheter Aortic Valve Replacement Era: Comprehensive Review of a Rare Complication

In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a revolutionary alternative for surgical aortic valve replacement (SAVR) for the treatment of severe symptomatic aortic stenosis in patients at high risk for surgery. Prosthetic aortic valve endocarditis is a serious complication after SAVR with high morbidity and mortality. Although numerous TAVR procedures have been performed worldwide, infective endocarditis (IE) after TAVR was reported in the literature in few cases only and in 0% to 2.3% of patients enrolled in large TAVR cohorts. Our aim was to review the literature for IE following TAVR and to discuss the diagnostic and management strategies of this rare complication. Ten case reports of IE after TAVR were identified, 8 of which were published as case reports and 2 of which were presented in congresses. Infective endocarditis occurred in a mean time period of 186 days (median, 90 days) after TAVR. Most cases were characterized by fever and elevated inflammatory markers. Infective endocarditis after TAVR shared some common characteristics with IE after SAVR, yet it has some unique features. Echocardiographic findings included leaflet vegetations, severe mitral regurgitation with rupture of the anterior leaflet, and left ventricle outflow tract to left atrium fistula. Bacteriologic findings included several atypical bacteria or fungi. Cases of IE were managed either conservatively by antibiotics and/or using surgery, and the overall prognosis was poor. Infective endocarditis after TAVR deserves prompt diagnosis and treatment. Until further evidence is present, IE after TAVR should be managed according to SAVR guidelines with modifications as needed on a case‐by‐case basis. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

A rare echocardiographic image of aortic prosthetic valve endocarditis complicated with paravalvular abscess,pseudoaneurysm and aorto‐right atrial fistula

Early infectious endocarditis (IE) occurs in 3% of prosthesis in the first 12 months. Early IE is more aggressive than late prosthetic valve endocarditis. Mortality remains high, despite combined medical and surgical treatment. We present a case of early IE in aortic prosthetic valve complicated with paravalvular abscess, pseudoaneurysm and aorto‐ right atrial fistula.     

Late subannular aortic root rupture following transcatheter aortic valve implantation presenting as ST elevation myocardial infarction

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis. Here, we present a case of late aortic root rupture presenting as ST‐elevation myocardial infarction five weeks following successful TAVI. Aortic root rupture is a rare complication of TAVI, which occurs in ～1% of procedures and usually arises during or soon after the procedure and is associated with high mortality (～50%). Early recognition of late‐presenting complications related to TAVI, including aortic root rupture, is essential for specialists and nonspecialists. © 2016 Wiley Periodicals, Inc.     

Rescue “valve in valve” implantation after late onset corevalve cusp rupture leading to acute massive aortic insufficiency

Transcatheter aortic valve implantation (TAVI) has emerged as a feasible and effective alternative to aortic valve replacement in patients at high surgical risk, and is associated with a lower risk of death at 1 year follow‐up when compared with standard therapy. In a recent large study, enrolling 663 high risk patients with symptomatic severe aortic stenosis TAVI with the use of CoreValve system has been associated with early and sustained clinical and hemodynamic benefits, with a cumulative mortality of 15.0% at 1 year follow‐up. This study has shown that paravalvular aortic regurgitation after successful TAVI is a frequent finding, being of mild entity in the vast majority of cases, whereas valvular regurgitation is almost entirely absent or mild. Of note, no cases of structural valve deterioration were reported. We report a case of a successful implantation of a CoreValve that complicated with late onset massive intravalvular aortic regurgitation, due to CoreValve cusp rupture, leading to low output state with acute pulmonary edema, which was successfully treated with “valve in valve” implantation. © 2011 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation for severe pure aortic regurgitation due to active aortitis

Aortitis is an uncommon systemic inflammatory disease affecting the aorta and its main branches. Severe aortic regurgitation (AR) represents a fearsome complication of aortitis and is associated with an increased mortality rate. Surgical aortic valve replacement represents the only treatment choice for these patients. However, it is associated with a higher risk of medium to long-term complications such as prosthetic valve detachment. This is the first reported case where severe AR secondary to aortitis was managed with transcatheter aortic valve implantation (TAVI). TAVI was safe and effective in this clinical setting and may be considered a viable alternative to high-risk surgery in these complex patients.     

With the back against the wall: TAVI in a patient with endocarditis

Transcatheter Aortic Valve Implantation (TAVI) is currently a well‐established therapeutic option in patients with severe aortic stenosis considered at prohibitive risk for open heart aortic valve replacement (Cribier et al., Circulation 2002;106:3006‐3008; Leon et al., Semin Thorac Cardiovasc Surg 2006;18:165‐174). We report a case of a patient with endocarditis by severe homograft aortic stenosis for which a TAVI procedure was performed with an excellent result. The patient was undergoing a presurgery standard screening in preparation for a planned aortic valve replacement operation when he developed a Staphyloccocus aureus sepsis. Transoesophageal echocardiography demonstrated an aortic valve vegetation. A few days later, the patient developed a stroke probably due to embolization of a vegetation. Given the clinical severity of the case a standard open heart aortic valve replacement was considered too risky and the patient underwent a TAVI procedure. Postintervention the patient had a spectacular evolution with fast normalization of the septic shock parameters and clinical status. Antibiotics were continued for a total of nine weeks. By the ambulatory controls at three weeks, two months and six months postdischarge, the patient was completely asymptomatic and his echocardiography showed a normally functioning aortic valve without indications of endocarditis. © 2012 Wiley Periodicals, Inc.     

Who is the right patient for TAVI?

Transcatheter aortic valve implantation (TAVI) has rapidly emerged as a valid therapeutic option for patients with severe symptomatic aortic stenosis who are high risk or ineligible for conventional surgical aortic valve replacement. Despite its minimally invasive nature, TAVI is invariably associated with complications in these old patients that may affect outcomes. Although the success of TAVI is determined by multiple factors, good screening and appropriate patient selection is crucial. Selection of the right patient includes the determination of risk levels and feasibility of a safe procedure in each individual case. Here, we describe below our critical appraisal of patient selection for TAVI.     

Transcatheter aortic valve implantation: Current status and future perspectives

Although surgical aortic valve replacement is the standard therapy for severe aortic stenosis(AS),about one third of patients are considered inoperable due to unacceptable surgical risk.Under medical treatment alone these patients have a very poor prognosis with a mortality rate of 50%at 2 years.Transcatheter aortic valve implantation(TAVI)has been used in these patients,and has shown robust results in the only randomized clinical trial of severe AS treatment performed so far.In this review,we will focus on the two commercially available systems:Edwards SAPIEN valve and CoreValve Revalving system.Both systems have demonstrated success rates of over 90%with 30-d mortality rates below 10%in the most recent transfemoral TAVI studies.Moreover,long-term studies have shown that the valves have good haemodynamic performance.Some studies are currently exploring the non-inferiority of TAVI procedures vs conventional surgery in high-risk patients,and long-term clinical results of the percutaneous valves.In this article we review the current status of TAVI including selection of patients,a comparison of available prostheses,results and complications of the procedure,clinical outcomes,and future perspectives.     

Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses—valve‐in‐valve technique

Background: The management of patients with degeneration of surgical bioprosthetic valve replacement remains a challenge because of the higher risk of re‐do aortic valve replacement. We present a case series of five patients with degenerated aortic bioprostheses treated with transfemoral transcatheter aortic valve implantation (TAVI). Methods: From December 2009 to May 2010, five patients with degenerated aortic valve bioprostheses (aortic valve area < 1 cm² or severe aortic regurgitation), an excessive operative risk (EuroSCORE ≥ 30%), symptoms of heart failure (NYHA ≥ III) and an internal diameter of bioprosthetic aortic valve 20.5 ± 0.5 mm were included. Procedures were performed without hemodynamic support using femoral arteries. Balloon valvuloplasty with a 20‐mm balloon under rapid pacing was carried out before valve implantation. The 26‐mm CoreValve prosthesis, 18‐F‐generation (Medtronic, Minneapolis, Minnesota) was inserted retrograde under fluoroscopic guidance. Invasive and echocardiographic measurements were done immediately before and after TAVI. Clinical followup and echocardiography were performed after procedure (mean followup 72 days ± 60, range: 176–30 days). Results: In all patients TAVI was successful with immediate decrease of transaortic peak‐to‐peak pressure (P = 0.002). Mild aortic regurgitation occurred in two patients and one patient received a new permanent pacemaker. Major adverse cardiac and cerebrovascular events did not arise. NYHA functional class improved in all patients and left ventricular ejection fraction increased (P = 0.019). Conclusion: Our experiences with the valve‐in‐valve technique using the CoreValve prosthesis suggest that transfemoral TAVI is feasible in high risk patients with degenerated aortic bioprostheses. © 2010 Wiley‐Liss, Inc.     

Prognostic benefit of transcatheter aortic valve implantation compared with medical therapy in patients with inoperable aortic stenosis

Objectives : To compare survival in patients with inoperable aortic stenosis who undergo transcatheter aortic valve implantation against those managed medically. Background : Without surgical correction, survival of patients with severe symptomatic aortic stenosis is poor. It is unknown whether patients undergoing transcatheter aortic valve implantation (TAVI) have a better prognosis than similar patients who are treated with medical management. Methods : Survival rates were compared in consecutive patients with severe symptomatic aortic stenosis who either underwent TAVI or continued on medical management following multidisciplinary team assessment. All patients had been turned down, or considered at unacceptably high risk, for conventional aortic valve surgery. Patients were reviewed in clinic or by telephone six monthly. Mortality data was obtained from the United Kingdom Office of National Statistics. Results : The study group included 85 patients aged 81 ± 7 years (range 62–94), of whom 48 were male. Thirty eight patients underwent TAVI while 47 patients were deemed unsuitable based on echocardiographic, angiographic, or clinical criteria and remained on medical therapy. The calculated EuroSCORE for the TAVI group was 11 ± 2 and for the medical group 9 ± 2 (P < 0.001). TAVI‐related procedural mortality was 2.6%, and 30‐day mortality was 5.2%. Among the medically‐treated patients, 14 (30%) underwent palliative balloon aortic valvuloplasty, with a trend toward improved survival (P = 0.06). During overall follow‐up of 215 ± 115 days there were a total of 18 deaths; TAVI N = 5 (13%); Medical N = 13 (28%) (P = 0.04). Conclusions : Patients with severe aortic valve disease who are not suitable for surgical aortic valve replacement have an improved prognosis if treated with transcatheter aortic valve implantation rather than continuing on medical management alone. © 2010 Wiley‐Liss, Inc.     

Impact des techniques interventionnelles dans le traitement de la valvulopathie aortique après revascularisation myocardique chirurgicale préalable

IntroductionPatients with a history of coronary artery bypass and aortic valve disease constitute a high-risk group for conventional redo surgery. The transcatheter aortic valve implantation (TAVI) may be an alternative for high-risk patients. The purpose of this study is to evaluate the impact of TAVI in the treatment of aortic valve disease after previous surgical coronary artery revascularization.Patients and methodsThis is a single-center retrospective, observational study, including 87 patients undergoing surgery for surgical heart valve replacement or TAVI from January 2007 to December 2013.ResultsThe introduction of transcatheter aortic valve implantation techniques has doubled the number of redo patients treated for aortic valve disease. From 2010 to 2013, the patients treated by conventional surgery diminished by 30%, with improved postoperative outcomes. This study allowed us to notice differences in patient's in terms of operative risk factors. For the same reasons no comparison was possible between 2 subgroup of patients. Hospital mortality was 6.4% for conventional aortic surgery and 20% for transcatheter aortic valve treatment.ConclusionSurgery remains the standard treatment for aortic valve disease even in redo patients, but TAVI becomes a very interesting tool as it may represent a tailored approach for our patients.     

Cirurgia cardíaca na estenose aórtica severa: o que mudou com o advento do tratamento percutâneo?

Introduction and objectiveTranscatheter aortic valve implantation (TAVI) is an alternative therapeutic approach to patients not considered suitable for surgical aortic valve replacement (SAVR) due to their high operative risk. We sought to assess the impact of TAVI on the profile and operative results of patients with severe aortic stenosis undergoing SAVR.MethodsA total of 214 patients were included, of whom 103 consecutive patients underwent isolated SAVR in 2005 and 111 in 2009. Patients’ demographic and operative data were collected retrospectively. Operative and one-year mortality and morbidity were analyzed.ResultsPatients’ mean age was 70 years, and 56% were female. Following the introduction of a TAVI program, patients undergoing conventional surgery were older, with more comorbidities. Overall 30-day and one-year mortality were 2.8% and 7.0%, respectively. After the introduction of TAVI, the observed mortality rate for SAVR decreased, but not significantly (operative mortality: 3.9% before TAVI vs. 1.8% after TAVI, p=NS; one-year mortality: 10% vs. 4.5%, p=NS). Striking differences were observed in morbidity (operative morbidity: 23.3% before TAVI vs. 13.5% after TAVI, p=0.047, and one-year morbidity: 20.4% vs. 9.9%, p=0.032).ConclusionsSince the introduction of a TAVI program at our center, the number of patients undergoing SAVR has increased, with a slight rise in surgical risk, but without worsening the final operative results. The implementation of a TAVI program has thus had a positive impact on the volume of procedures, patient selection and outcomes in SAVR.     

Aortic valve cusp aneurysm as a result of blood culture-negative infective endocarditis,interesting echocardiographic and surgical images

Compared to mitral valve aneurysms, aortic valve (AV) aneurysm is a more rare and serious complication of infective endocarditis (IE). Early surgical intervention and valve replacement are required in order to prevent further complications such as embolization and rupture of aneurysm. We described a case of severe aortic regurgitation (AR) as a result of an aortic valve aneurysm in a patient with history of end-stage renal disease (ESRD) in whom the hemodialysis catheter had not been changed for a year.     

Implantação percutânea de válvula aórtica em doente muito jovem

Transcatheter aortic valve implantation (TAVI) is the standard treatment for patients with severe aortic stenosis and unacceptable surgical risk. These are usually elderly patients with multiple comorbidities.We report the case of a 20-year-old man with mandibuloacral dysplasia, an extremely rare premature ageing syndrome, and severe symptomatic aortic stenosis, referred to our center for TAVI after being considered unsuitable for surgical aortic valve replacement. TAVI by a transfemoral approach was performed successfully. Severe acute respiratory failure that did not respond to optimal conventional treatment led us to employ venovenous extracorporeal membrane oxygenation. The device was removed after 10 days, and the patient was discharged home 27 days later. At one-year follow-up he is in NYHA class I with full functional autonomy. To the best of our knowledge, this is the youngest patient to undergo TAVI reported in the literature.