Commentary: Greater risk of infective endocarditis after biologic valve replacement: A word of caution before expanding the indications to younger patients

Abstract

Central MessageBiologic valves may be associated with greater risk of infective endocarditis. This should be considered when making prosthetic valve selection, especially for younger patients.See Article page XXX. Biologic valves may be associated with greater risk of infective endocarditis. This should be considered when making prosthetic valve selection, especially for younger patients. See Article page XXX. Prosthetic valve endocarditis (PVE) is a life-threatening disease that accounts for 10% to 30% of all cases of infective endocarditis (IE).1Pettersson G.B. Hussain S.T. Surgical treatment of aortic valve endocarditis.in: Cohn L.H. Adams D.H. Cardiac Surgery in the Adult. 5th ed. McGraw Hill Education, 2018: 731-741Google Scholar Approximately 50% to 60% of PVE cases require surgical intervention for successful treatment.2Wang A. Athan E. Pappas P.A. Fowler V.G. Olaison L. Paré C. et al.Contemporary clinical profile and outcome of prosthetic valve endocarditis.JAMA. 2007; 297: 1354-1361Google Scholar,3Hill E.E. Herregods M.C. Vanderschueren S. Claus O. Peetermans W.E. Herijgers P. Management of prosthetic profile and outcome of prosthetic valve endocarditis.Am J Cardiol. 2008; 101: 1174-1178Google Scholar Despite the improvements in early diagnosis and medical management, PVE is associated with a high surgical mortality of 20% to 30%.2Wang A. Athan E. Pappas P.A. Fowler V.G. Olaison L. Paré C. et al.Contemporary clinical profile and outcome of prosthetic valve endocarditis.JAMA. 2007; 297: 1354-1361Google Scholar,3Hill E.E. Herregods M.C. Vanderschueren S. Claus O. Peetermans W.E. Herijgers P. Management of prosthetic profile and outcome of prosthetic valve endocarditis.Am J Cardiol. 2008; 101: 1174-1178Google Scholar The choice of prosthetic valves in the setting of IE has been a subject of controversy for several decades. There are conflicting reports in the literature regarding long-term survival and freedom from recurrence of IE.4Cahill T.J. Prendergast B.D. Infective endocarditis.Lancet. 2016; 387: 882-893Google Scholar, 5Toyoda N. Itagaki S. Tannous H. Egorova N.N. Chikwe J. Bioprosthetic versus mechanical valve replacement for infective endocarditis: focus on recurrence rates.Ann Thorac Surg. 2018; 106: 99-106Google Scholar, 6Glaser N. Jackson V. Holzmann M.J. Franco-Cereceda A. Sartioy U. Prosthetic valve endocarditis after surgical aortic valve replacement.Circulation. 2017; 136: 329-331Google Scholar, 7Said S.M. Abdel Sattar Z.M. Schaff H.V. Greason K.L. Daly R.C. Pochettino A. et al.Outcomes of surgery for infective endocarditis: a single-centre experience of 801 patients.Eur J Cardiothorac Surg. 2018; 53: 435-439Google Scholar Accordingly, the current guidelines do not provide guidance on the comparative risk of IE for biologic and mechanical valves.8Otto C.M. Nishimura R.A. Bonow R.O. Caravello B.A. Erwin J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease.Circulation. 2021; 143: e72-e227Google Scholar, 9Vahanian A. Beyersdorf F. Praz F. Milojevic M. Baldus S. Bauezachs J. et al.2021 ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2021; 60: 727-800https://doi.org/10.1093/ejcts/ezab389Google Scholar, 10Izumi C. Eishi K. Ashihara K. Arita T. Otsuji Y. Kunihara T. et al.JCS/JSCS/JATS/JSVS 2020 guidelines on the management of valvular heart disease.Circ J. 2020; 84: 2037-2119https://doi.org/10.1253/circj.CJ-20-0135Google Scholar However, recent studies, including single-center and nationwide, population-based studies have suggested a possible increased risk of PVE after biologic valve replacement for native valve IE.7Said S.M. Abdel Sattar Z.M. Schaff H.V. Greason K.L. Daly R.C. Pochettino A. et al.Outcomes of surgery for infective endocarditis: a single-centre experience of 801 patients.Eur J Cardiothorac Surg. 2018; 53: 435-439Google Scholar,11Ruibno A.S. Della Ratta E.E. Gabliati D. Ashurov R. Galgano V.L. Montella A.P. et al.Can prosthesis type influence the recurrence of infective endocarditis after surgery for native valve endocarditis? A propensity weighted comparison.Eur J Cardiothorac Surg. 2021; 60: 1388-1394Google Scholar, 12Kytö V. Sipilä J. Ahtela E. Rautava P. Gunn J. Mechanical versus biologic prostheses for surgical valve replacement in patients aged 50 to 70.Ann Thorac Surg. 2020; 110: 102-110Google Scholar, 13Østergaard L. Valeur N. Ihlemann N. Smerup M.H. Bundgaard H. Gislason G. et al.Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement.Eur Heart J. 2018; 19: 2668-2675Google Scholar Moreover, a systemic review and meta-analysis from the Mayo Clinic indicates that biologic valves may be associated with a greater risk of IE than mechanical valves in patients with no history of IE before surgery.14Anantha-Narayanan M. Reddy Y.N.V. Sundaram V. Murad M.H. Erwin P.J. Baddour L.M. et al.Endocarditis risk with bioprosthetic and mechanical valves: systematic review and meta-analysis.Heart. 2020; 106: 1413-1419Google Scholar In this issue of the Journal, Lee and colleagues15Lee H.A. Chien-Chia Wu V. Chan Y.S. Cheng Y.T. Lee J.K. Chu P.H. et al.Infective endocarditis after surgical aortic or mitral valve replacement: a nationwide population-based study.J Thorac Cardiovasc Surg. December 23, 2021; ([Epub ahead of print])Google Scholar from Taiwan reported the outcomes of left-sided native valve endocarditis for biologic and mechanical valve replacement. Based on a large study population with sound statistics, they provided robust data indicating that patients with a biologic prosthesis had a significantly greater risk of IE than those with a mechanical valve for all left-sided surgical aortic and mitral valve replacements taken together, for single-aortic replacement (SAVR) or single-mitral valve replacement, and for double-valve replacement. Moreover, they observed a greater risk of developing IE for biologic valves than mechanical valves regardless of whether the IE was active or old, and with or without a history of IE. Most updated valve guidelines from Europe (2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines),9Vahanian A. Beyersdorf F. Praz F. Milojevic M. Baldus S. Bauezachs J. et al.2021 ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2021; 60: 727-800https://doi.org/10.1093/ejcts/ezab389Google Scholar and Japan (Japan Circulation Society/Japanese Society for Cardiovascular Surgery/Japanese Association for Thoracic Surgery/Japanese Society for Vascular Surgery 2020 Guidelines)10Izumi C. Eishi K. Ashihara K. Arita T. Otsuji Y. Kunihara T. et al.JCS/JSCS/JATS/JSVS 2020 guidelines on the management of valvular heart disease.Circ J. 2020; 84: 2037-2119https://doi.org/10.1253/circj.CJ-20-0135Google Scholar recommend biologic valves in patients older than 65 years of age, mechanical valves in patients younger than 60 years of age, and either type of valve in patients between 60 years and 65 years for SAVR. In contrast, the 2020 American College of Cardiology/American Heart Association Guidelines recommend either type of valve in patients between 50 and 65 years of age,8Otto C.M. Nishimura R.A. Bonow R.O. Caravello B.A. Erwin J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease.Circulation. 2021; 143: e72-e227Google Scholar which reflects the increasing uncertainty in the intermediate-age groups. Despite these recommendations, biologic SAVRs have been more frequently performed in younger patients over the last few decades.16Savage E.B. Saha-Chaudjri P. Asher C.R. Brennan J.M. Gammie J.S. Outcomes and prosthesis choice for active aortic valve infective endocarditis: analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database.Ann Thorac Surg. 2014; 98: 806-814Google Scholar Moreover, indications for transcatheter aortic valve replacement (TAVR) have been expanded from prohibitive to high- or intermediate-risk of surgery in older populations to low-risk patients with longer life expectancy.17Mack M.J. Thourani R. Kodali S.K. Russo M. Kapadia S.R. Malaisrie S.C. et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Google Scholar,18Popma J.J. Deeb G.M. Yakuubov S.J. Mumtaz M. Gada H. O’Hair D. et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380: 1706-1715Google Scholar Although the precise mechanisms underlying the development of PVE in biologic prostheses and TAVR valves remain to be determined, there is a growing body of literature indicating that younger age is a risk factor for the development of PVE in biologic valves7Said S.M. Abdel Sattar Z.M. Schaff H.V. Greason K.L. Daly R.C. Pochettino A. et al.Outcomes of surgery for infective endocarditis: a single-centre experience of 801 patients.Eur J Cardiothorac Surg. 2018; 53: 435-439Google Scholar,12Kytö V. Sipilä J. Ahtela E. Rautava P. Gunn J. Mechanical versus biologic prostheses for surgical valve replacement in patients aged 50 to 70.Ann Thorac Surg. 2020; 110: 102-110Google Scholar,14Anantha-Narayanan M. Reddy Y.N.V. Sundaram V. Murad M.H. Erwin P.J. Baddour L.M. et al.Endocarditis risk with bioprosthetic and mechanical valves: systematic review and meta-analysis.Heart. 2020; 106: 1413-1419Google Scholar and TAVR.19Alexis S.L. Malik A.H. George I. Hahn R. Khalique O.K. Seetharam K. et al.Infective endocarditis after surgical and transcatheter aortic valve replacement: a state of art review.J Am Heart Assoc. 2020; 9: e0173347https://doi.org/10.1161/JAHA.120.017347Google Scholar, 20Regueiro A. Linke A. Latib A. Ihlemann N. Urena M. Walther T. et al.Association between transcatheter aortic valve replacement and subsequent infection endocarditis and in-hospital death.JAMA. 2016; 316: 1083-1092Google Scholar, 21Mangner N. Woitek F. Haussig S. Schlotter F. Stacgel G. Hollriegel R. et al.Incidence, predictors, and outcome of patients developing infective endocarditis following transfemoral transcatheter aortic valve replacement.J Am Coll Cardiol. 2016; 67: 2907-2908Google Scholar We must remember that the longer the biologic valve is in the recipient, the greater the rates of degeneration and IE, which may result in greater mortality. This is particularly important for younger patients. Thus, we must proceed with caution in expanding the indications for biologic prostheses and TAVR valves to younger patients. Infective endocarditis after surgical aortic or mitral valve replacement: A nationwide population-based studyThe Journal of Thoracic and Cardiovascular SurgeryPreviewEvidence regarding the incidence of prosthetic valve endocarditis and its association with the use of mechanical or biologic prosthetic valves is limited. Full-Text PDF