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The risk of infective endocarditis is the same with transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR), but the risk of dying from infective endocarditis is greater with TAVI than with SAVR, reported Professor Laurent Fauchier (Tours Regional University Hospital, Tours, France) in a Late-Breaking Science presentation yesterday (Abstract 5844).
TAVI is being used increasingly as an alternative to SAVR in patients with aortic stenosis, but its association with infective endocarditis, which carries significant morbidity and mortality, is not well defined. “To investigate the risks of infective endocarditis with TAVI and SAVR, and the prognosis, we conducted a nationwide study of patients with aortic stenosis from French hospitals,” says Prof. Fauchier. “Because we wanted to compare the standard surgical approach with the usual percutaneous TAVI procedure, the study focussed on patients undergoing isolated SAVR or percutaneous TAVI and excluded patients undergoing more complex surgical procedures or surgical TAVI.”
Around 47,000 patients with TAVI and 60,000 patients with SAVR, treated between 2010 and 2018, were included from the French administrative hospital-discharge database. “The TAVI patients were older and had more comorbidities,” says Prof. Fauchier, “and this is likely to be part of the reason they received TAVI instead of SAVR.” To account for the difference in baseline characteristics across the groups, patients in each arm were propensity-score matched, resulting in around 16,000 patients in each group.
The yearly rate of infective endocarditis was 1.9% with TAVI and 1.7% with SAVR (relative risk 1.09; 95% confidence interval [CI] 0.96–1.23; p=0.17).
The group also sought to determine which TAVI patients were at a greater risk of developing infective endocarditis and the four main risk factors identified were: white race, male, anaemia and atrial fibrillation.
Among patients developing post-procedure infective endocarditis, those having undergone TAVI had a significantly higher risk of mortality than those undergoing SAVR (relative risk 1.32; 95% CI 1.08–1.60; p=0.005). “We did not analyse the reasons for this higher risk of death with TAVI, but we can make some suggestions,” says Prof. Fauchier. “The most obvious possibility is that these are more frail patients, at least some of whom may have received TAVI due to SAVR contraindications. It is likely that their frailty may also have led to less aggressive treatment for infective endocarditis and earlier use of palliative care than in healthier patients.”
In conclusion, Prof. Fauchier says, “We want to stress to cardiologists that, although the TAVI procedure and the subsequent hospital stay are shorter and may appear to be less risky than SAVR, the risk of infective endocarditis is no lower with TAVI than following surgery. It can be easy to forget TAVI is an invasive procedure that carries a risk of infection and patients who may be at a high risk of post-TAVI infective endocarditis should receive appropriate anti-infective prophylaxis, just as patients undergoing SAVR do.”
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