MIGHTY MITIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Transcatheter Aortic Valve Replacement (TAVR) is the mainstay treatment of severe aortic stenosis especially in the elderly with multiple comorbidities and is emerging as an alternative to surgical aortic valve replacement (SAVR). (1) The rate of infective endocarditis (IE) following TAVR has been reported to be around 1.5%.(2) Herein, we describe a case where the patient developed prosthetic valve endocarditis (PVE) 2 months after undergoing TAVR. CASE PRESENTATION: A 73-year-old male presented to the emergency with cough, chills, and bilateral lower extremity swelling for a week. His medical history was significant for hypertension, hyperlipidemia, type 2 diabetes mellitus, bradycardia status post dual lead pacemaker (2013), and severe aortic stenosis status post TAVR (26mm SAPIEN 3 valve via right femoral artery- TAVR was done 2 months prior to this presentation). The patient underwent a dental procedure 3 weeks after the TAVR and did not receive any antibiotic prophylaxis prior to the dental procedure. Duke Criteria indicated ‘Possible infective endocarditis (IE)’. Transthoracic echocardiogram (TTE) did not show any vegetation. Blood cultures yielded Streptococcus mitis/ oralis. Transesophageal echocardiogram (TEE) showed 0.6 X 0.2cm vegetation on the left coronary cusp of the prosthetic aortic valve and mild paravalvular aortic insufficiency. The pacemaker was vegetation-free. He was started on intravenous (IV) ceftriaxone, responded well to it, and was discharged with a 6weeks course of IV ceftriaxone and he was referred to cardiothoracic surgery for further evaluation. DISCUSSION: IE is an uncommon complication after TAVR. PVE associated with TAVR is difficult to diagnose and has a dismal prognosis so TAVR- IE deserves prompt diagnosis and treatment. PVE presents with fever, new or changing heart murmur, new or worsening heart failure, or new or progressive cardiac conduction abnormalities. The most frequently encountered pathogens in early PVE (within two months of TAVR) are S. aureus and coagulase-negative staphylococci followed by gram-negative bacilli and fungi. The most frequently encountered pathogens in intermediate PVE (2 to 12 months after TAVR) and late PVE (more than 12 months after TAVR) are streptococci and S. aureus followed by coagulase-negative staphylococci and enterococci. The main sources of PVE are dental interventions and respiratory, skin, urological, and gastrointestinal infections.(2) Studies have shown that men are found to be affected by IE more often than women. (3) CONCLUSIONS: As per the American Heart Association (AHA) and the European Society for Cardiology (ESC) guidelines, PVE should be treated with a bactericidal agent for at least six weeks. Guidelines recommend early surgery in complicated cases including those with heart failure, perivalvular complications, and high risk of embolism. Emphasis should also be given on any pre-procedure prophylaxis. Reference #1: Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98. Reference #2: Amat-Santos IJ, Ribeiro HB, Urena M, Allende R, Houde C, Bédard E, Perron J, Delarochellière R, Paradis JM, Dumont E, Doyle D, Mohammadi S, Côté M, San Roman JA, Rodés-Cabau J. Prosthetic valve endocarditis after transcatheter valve replacement: A systematic review. JACC Cardiovasc Interv. 2015;8:334–346. Reference #3: Olsen NT, Backer O De, Thyregod HGH, Vejlstrup N, Bundgaard H, Søndergaard L. Structural Heart Disease Prosthetic Valve Endocarditis After Transcatheter Aortic Valve Implantation. 2015;1–9. DISCLOSURES: No relevant relationships by Sanya Chandna, source=Web Response No relevant relationships by Kesavan Sankaramangalam, source=Web Response No relevant relationships by Monarch Shah, source=Web Response