Risk Of Prosthetic Valve Endocarditis Research Articles

Statin use after valvular heart surgery is associated with a decreased risk of prosthetic valve endocarditis

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Sanming Project of Medicine in Shenzhen, China; HKU-SZH Fund for Shenzhen Key Medical Discipline Background Prosthetic valve endocarditis (PVE) is a rare but serious complication following valvular heart surgery for which preventive strategies remain unknown. Recent epidemiological evidence suggests that statins may reduce the risk of infections and infection-related complications. Purpose We aim to assess the association between statin use and the risk of prosthetic valve endocarditis in patients undergoing valvular heart surgery. Methods In all patients undergoing valvular heart surgery in Hong Kong between 2010 and 2021, statin use was ascertained by ≥14-day consecutive filled prescriptions after surgery. Stepwise Poisson regression was applied to identify predictors of PVE. Baseline characteristics between statin nonusers (N = 1400) with statin users (N = 976) were balanced using the inverse probability of treatment weighting. Cox proportional-hazard models with competing risk regression were further performed to estimate the risk of PVE and cardiovascular mortality associated with statin use. Results Our study included 2376 patients; the mean age was 57.8±14.2 years, and 54.4% were males. Over a median follow-up of 5.5 years (interquartile range 2.8-8.6), PVE occurred in 93 patients (6.75 [95% CI 5.51-8.26] PVE events per 1000 person-years). PVE was associated with New York Heart Association Class (Relative Risk [RR] 1.22, 95% Confidence Interval [CI] 1.01-1.45; P = 0.035), prior infective endocarditis (RR 8.64, 95% CI 5.58-13.19; P < 0.001), and aortic valve replacement (RR 1.67, 95% CI 1.11-2.53; P = 0.014). Compared with non-use, statin use was associated with a 47% lower risk of PVE incidence (multivariable-adjusted subdistribution hazard ratio [SHR] 0.53, 95% CI 0.33-0.83; P = 0.006) (Figure 1). This inverse association with the risk of PVE was duration dependent, with an adjusted SHR of 0.60 (95% CI 0.47-0.73; P < 0.001) per year of statin use. Results were consistent across subgroups of sex (male vs female), the number of valvular procedures (single vs multiple), and prosthesis type (mechanical vs biological), but not in groups aged ≤60 years or with prior infective endocarditis (Figure 2). Statin use was associated with a 45% decreased risk of cardiovascular death (SHR 0.55, 95% CI 0.36-0.84; P = 0.006). Conclusions In patients undergoing valvular surgery, post-operative statin use is associated with a lower risk of PVE. These results provide new avenues for preventing PVE and hence valve failure.

Prosthetic Valve Endocarditis in Patients Undergoing TAVR Compared to SAVR: A Systematic Review and Meta-Analysis

BackgroundThe risk of prosthetic valve endocarditis (PVE) in patients who underwent transcatheter aortic valve replacement (TAVR) is presumed to be high. MethodsElectronic databases were searched to identify articles comparing the rate of PVE in post-TAVR and post-surgical aortic valve replacement (SAVR) patients. Pooled adjusted odds ratio (OR) was computed using a random-effects model. ResultsA total of 19 studies consisting of 84,288 patients, were identified. There was no significant difference in the odds of PVE between patients undergoing TAVR and SAVR, at 30-day (OR 0.62, 95% confidence interval (CI) 0.20–1.92, p = 0.41), 1-year (OR 0.99 95% CI 0.89–1.11, p = 0.84), 2-year (OR 1.02 95% CI 0.68–1.54, p = 0.92) and 5-year (OR 1.03 95% CI 0.80–1.33, p = 0.81). A subgroup sensitivity analysis also showed no significant inter-group differences in the rate of PVE at all time points, when stratified by the study design (clinical trial vs. observational), type of TAVR valves used (self-expanding bioprosthetic valves vs. balloon expanded bioprosthetic valves) and surgical risk of patients (high vs. intermediate vs. low). There was no heterogeneity (I2 = 0%) in the outcomes of the included studies at 30-day, 1-year and 2-year, while the heterogeneity in studies at 5-year was minimal (I2 = 22%). ConclusionsIn comparison to SAVR, both short and long-term risk of prosthetic valve endocarditis appears to be identical in patients undergoing TAVR. This risk is unaffected by the type of valve, duration of follow-up, study design and surgical risk of the patients.

Prosthetic valve endocarditis after transcatheter or surgical aortic valve replacement with a bioprosthesis: results from the FinnValve Registry.

The aim of this study was to compare the risk of prosthetic valve endocarditis (PVE) in patients with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). The FinnValve registry included data from 6,463 consecutive patients who underwent TAVR (n=2,130) or SAVR (n=4,333) with a bioprosthesis from 2008 to 2017. PVE was defined according to the modified Duke criteria. In this study, the incidence of PVE was 3.4/1,000 person-years after TAVR, and 2.9/1,000 person-years after SAVR. In competing risk analysis there was no significant difference in the risk of PVE between patients with TAVR and SAVR over an eight-year observational period. Male gender (HR 1.73, 95% CI: 1.04-2.89) and deep sternal wound infection or vascular access-site infection (HR 5.45, 95% CI: 2.24-13.2) were positively associated with PVE, but not type of procedure (HR 1.09, 95% CI: 0.59-2.01) in multivariate analysis. The mortality rate was 37.7% at one month and increased to 52.5% at one year. Surgical treatment was independently associated with decreased in-hospital mortality (HR 0.34, 95% CI: 0.21-0.61). PVE is rare, and its risk is similar after TAVR and SAVR. ClinicalTrials.gov Identifier: NCT03385915. https://clinicaltrials.gov/ct2/show/NCT03385915.

1510. Treatment of Asymptomatic Bacteriuria prior to Transcatheter Aortic Valve Replacement

BackgroundBased on large population-based studies, the risk of prosthetic valve endocarditis (PVE) after surgical aortic valve replacement is 0.57% per person year. There is no causal link from asymptomatic bacteriuria (ASB) to PVE; however, antibiotics are often prescribed in an abundance of caution given the catastrophic downside. The risk of PVE is yet to be determined in patients who receive a transcatheter aortic valve replacement (TAVR), but likely lower due to the minimally invasive approach. At our institution, ASB is heterogeneously treated with antibiotics prior to TAVR. Herein we quantified some untoward outcomes of treatment of ASB pre-TAVR.MethodsA single-center retrospective study was conducted for patients who underwent TAVR between October 2012 and June 2017. Pre- and post-procedural urinalyses (UA), culture results, antibiotic regimens, development of resistance, symptoms of UTI, 30-day readmission rates, and 30- and 90-day mortality rates were collected.ResultsA total of 296 patients with median age of 83 (range 49–97) underwent TAVR. Two hundred and sixty UAs with reflex to culture (137 of which reflexed) and eight additional urine cultures (UC) were sent. One hundred and thrity-three of 145 patients cultured had no documented symptoms. There were 44 patients with positive UC, of which nine (20%) had symptoms. Of the 35 with ASB, 27 received antibiotics prior to TAVR (77%). Among those who were treated, there was one case of C. diff, three cases of development of resistance in an organism previously isolated and three cases of newly acquired MDRO. This amounts to a number needed to harm of 3.86. There were no cases of any of these outcomes, 30-day readmission or death within 90 days for the ASB patients who did not receive treatment. In the treatment group, there was one case of bacteremia for which the causative organism was different from the organism isolated in UC.ConclusionIn this small cohort of mostly elderly TAVR patients, the rate of ASB was high as expected and most were treated. We documented cases of potential harm associated with antibiotic treatment, and found no such harm episodes in the untreated group. Given the high number needed to harm and the historically low risk of PVE, antimicrobial stewardship experts should continue to encourage avoidance of antibiotics for ASB, including for patients undergoing invasive and minimally invasive cardiac procedures.Disclosures All authors: No reported disclosures.

High Risk of Prosthetic Valve Endocarditis and Death After Valve Replacement Operations in Dialysis Patients

Despite a high burden of dialysis access-related bloodstream infections and an increasing incidence of endocarditis, few data are available addressing the risk of prosthetic valve endocarditis (PVE) in the dialysis population. We sought to assess the risk of PVE and death after valve replacement operations in patients receiving long-term dialysis. A matched retrospective cohort study was conducted comprising patients admitted for valve replacement operations at two university hospitals. Patients without dialysis were matched 1:1 with dialysis patients by valve(s) replaced, year of operation, and presence of active endocarditis as the indication for valve replacement. Patient characteristics were compared using χ(2) and t tests. The development of PVE was defined by use of the modified Duke criteria and analyzed with Cox proportional hazards regression. Two hundred seventy-eight patients were included, with 139 in either cohort. The PVE risk per year of follow-up was 0.14 in the dialysis cohort and 0.03 in the nondialysis cohort. Dialysis remained a risk factor (adjusted hazard ratio 5.61 [95% confidence interval, 2.17 to 14.5], p= 0.0004) after age and race were controlled for. The 5-year survival rate was lower after valve replacement operation in the dialysis group (25.4%) than in the nondialysis group (75.9%, p < 0.001). The risk of PVE and death after valve replacement operations in dialysis patients is substantial and significantly higher than in patients without dialysis. These findings highlight the importance of a careful preoperative risk-benefit assessment and underscore the need to prevent hemodialysis-related bloodstream infections.

Successful Medical Treatment of Bioprosthetic Pulmonary Valve Endocarditis Caused by Methicillin-Resistant Staphylococcus aureus

The mortality risk of prosthetic valve endocarditis is known to be increased in cases in which staphylococci are the causative organisms. Previous recommendations have concentrated on early surgical management of this condition, but there are now reports that these infections can be treated medically, thus leaving prosthetic material in situ. We describe a case of methicillin-resistant Staphylococcus aureus endocarditis on a bovine pericardial pulmonary valve that responded to antibiotic therapy without the need for surgical intervention.

Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia

Staphylococcus aureus is a common cause of bacteremia and of native valve infective endocarditis. However, the risk of endocarditis in patients with a prosthetic valve who develop S. aureus bacteremia is unclear. The aim of this study was to define the risk of prosthetic valve endocarditis in patients with S. aureus bacteremia. All patients with a prosthetic valve or ring who developed S. aureus bacteremia during the 94-month study period were prospectively evaluated. The modified Duke criteria were used for the diagnosis of endocarditis. Patients were followed up for 12 weeks after the initial diagnosis of S. aureus bacteremia. The overall rate of definite prosthetic valve endocarditis among the study patients was 26/51 (51%). The risk of endocarditis was similar in patients with late (>or=12 months after valve implantation) vs. early S. aureus bacteremia (<12 months after prosthetic valve implantation) (50% vs. 52%, P=1.0), mitral vs. aortic prostheses (62% vs. 48%, P=0.24), and mechanical vs. bioprosthetic valves (62% vs. 44%, P=0.29). The 12-week mortality was higher among patients with definite vs. possible endocarditis (62% vs. 28%, P=0.019). In this investigation, approximately half of all patients with prosthetic valves who developed S. aureus bacteremia had definite endocarditis. The risk of endocarditis was independent of the type, location, or age of the prosthetic valve. The mortality of prosthetic valve endocarditis is high. All patients with a prosthetic valve who develop S. aureus bacteremia should be aggressively screened and followed for endocarditis.

1143-135 The risk of prosthetic valve endocarditis in patients with staphylococcus aureus bacteremia

1143-135 The risk of prosthetic valve endocarditis in patients with staphylococcus aureus bacteremia

Risk factors for the development and outcome of prosthetic valve endocarditis

Prosthetic valve endocarditis (PVE) was encountered in 20 out of 821 patients (2.4%) who underwent valve replacement between 1 January 1981 and 30 June 1985. At a follow-up time 6–60 months later the actuarial risk of PVE was 1% yr−1. The incidence of PVE was higher after bioprosthetic replacement (5%), after aortic valve replacement (3.4%) and in patients operated on for antecedent endocarditis of either the native or the prosthetic valve (10%). The overall mortality was 40%. Surgical treatment improved chances of survival (27% mortality) compared to medical treatment (80% mortality) independently of other factors (bioprosthesis or mechanical prosthesis, aortic or mitral position, early or late onset PVE).

Community-acquired febrile illness in patients with prosthetic heart valves.

We prospectively studied 40 patients with prosthetic heart valves and community-acquired febrile illness. The mean age of the group studied was 35.2 +/- 12.8 years, and the mean length of time that the prosthetic valve had been in place was 53.4 +/- 43.7 months. There was a high incidence (37.5%) of infectious endocarditis in the patients studied, with a total mortality of 15% in the group. The presence of a new regurgitant murmur, skin or retinal lesions, splenomegaly, vegetations shown on echocardiograms, and persistent bacteremia was associated with infectious endocarditis (P less than .05). The patients with mechanical Starr-Edwards valves had a significantly higher incidence (P less than .001) of infectious endocarditis than those with other types of prosthetic valves implanted in our hospital. Complete evaluation is mandatory in febrile patients with prosthetic heart valves because of the high risk of prosthetic valve endocarditis as the cause of the fever.