In-hospital infective endocarditis following transcatheter aortic valve replacement: a cross-sectional study of the National Inpatient Sample database in the USA

doi:10.1016/j.jhin.2018.05.014

Journal of Hospital Infection

Volume 100, Issue 4, December 2018, Pages 444-450

https://doi.org/10.1016/j.jhin.2018.05.014 Get rights and content

Summary

Background

While the utilization of transcatheter aortic valve replacement (TAVR) for patients with severe aortic stenosis has been increasing, in-hospital infective endocarditis (IE) following TAVR has not been well described.

Aim

To identify in-hospital IE following TAVR.

Methods

All patients who underwent TAVR between 2012 and 2014 were identified using the National Inpatient Sample database. Multi-variate logistic regression was performed to identify the predictors of in-hospital IE after TAVR.

Findings

Of the 41,025 patients who received TAVR, 120 patients (0.3%) developed in-hospital IE. Viridans group streptococci (20.8%) was the most frequent causative organism for in-hospital IE, followed by Staphylococcus aureus (16.7%) and enterococci (8.3%). Patients who developed in-hospital IE after TAVR had significantly higher rates of death (20.8% vs 4.1%, P<0.001), septic shock (16.7% vs 0.8%, P<0.001), cardiogenic shock (12.5% vs 3.4%, P=0.02), acute kidney injury requiring haemodialysis (16.7% vs 1.6%, P<0.001), bleeding requiring transfusion (29.2% vs 11.3%, P=0.01), myocardial infarction (12.5% vs 2.1%, P<0.001) and permanent pacemaker removal (4.2% vs 0.05%, P<0.001) compared with patients without IE. Independent predictors of in-hospital IE after TAVR include younger age [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.89–0.95], drug abuse (OR 48.9, 95% CI 6.9–347.3) and human immunodeficiency virus (HIV) infection (OR 7.8, 95% CI 1.4–44.4).

Conclusion

IE occurred in 0.3% of patients after TAVR during the same hospitalization, resulting in higher rates of adverse outcomes including mortality. Patients with younger age, a history of drug abuse or HIV infection are at greater risk of in-hospital IE following TAVR, and would benefit from vigilant preventive measures perioperatively.

Section snippets

Background

Aortic stenosis (AS) is the most common type of valvular heart disease, and the prevalence of severe AS is 3.4% in the elderly [1]. The utilization of transcatheter aortic valve replacement (TAVR) has been increasing rapidly for treatment of patients with symptomatic severe AS who are at prohibitive or high surgical risk. Infective endocarditis (IE) is the third or fourth most common life-threatening infection [2]. The long-term incidence of IE following TAVR (TAVR-IE) is 3.1%, with a median

Data source and study population

This study used the National Inpatient Sample (NIS) database from 2012 to 2014, developed by the Agency for Healthcare Research and Quality (AHRQ). The NIS database, the largest publicly available healthcare database in the USA, approximates a 20% stratified sample of discharges from all US community hospitals, and represents more than 97% of the US population [8]. The sampling design of this nationally representative NIS database has been validated previously in numerous publications [9], [10]

Results

Of the 107,441,456 discharge records in the NIS data from 1^st January 2012 to 31^st December 2014, 41,025 patients (aged ≥18 years) who underwent TAVR were identified. Table I shows the comparison of clinical characteristics between patient groups with and without in-hospital TAVR-IE. One hundred and twenty patients (0.3%) developed in-hospital TAVR-IE. The patients with in-hospital TAVR-IE were younger and had a higher burden of comorbidities, including drug abuse, human immunodeficiency virus

Discussion

In this study of a large nationally representative data set of US hospitals examining in-hospital IE following TAVR between 2012 and 2014, several important findings were identified. First, the incidence of healthcare-associated in-hospital IE following TAVR was 0.3%, with viridans group streptococci being the most common causative organism. Second, patients with TAVR-IE experienced significantly higher incidence rates of in-hospital complications including mortality than those without IE after

Conflict of interest statement

None declared.

Funding sources

This work was supported by grants from the Michael Wolk Heart Foundation and the New York Cardiac Center, Inc., New York, USA.

References (33)

V.T. Nkomo et al.
Burden of valvular heart diseases: a population-based study
Lancet
(2006)
I.J. Amat-Santos et al.
Prosthetic valve endocarditis after transcatheter valve replacement: a systematic review
JACC Cardiovasc Intervent
(2015)
R. Engelman et al.
The Society of Thoracic Surgeons practice guideline series: antibiotic prophylaxis in cardiac surgery. Part II: antibiotic choice
Ann Thorac Surg
(2007)
R.A. Nishimura et al.
2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Thorac Cardiovasc Surg
(2014)
S. Pant et al.
Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011
J Am Coll Cardiol
(2015)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chron Dis
(1987)
D.C. DeSimone et al.
Incidence of infective endocarditis due to viridans group streptococci before and after the 2007 American Heart Association's prevention guidelines: an extended evaluation of the Olmsted County, Minnesota, Population and Nationwide Inpatient Sample
Mayo Clin Proc
(2015)
D.R. Holmes et al.
Annual outcomes with transcatheter valve therapy: from the STS/ACC TVT Registry
J Am Coll Cardiol
(2015)
P.B. Lockhart et al.
Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia
J Am Dent Assoc
(2009)
S.J. Chen et al.
Dental scaling and risk reduction in infective endocarditis: a nationwide population-based case-control study
Can J Cardiol
(2013)

C.M. Otto et al.

2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents

J Am Coll Cardiol

(2017)

G. Pons-Llado et al.

Findings on Doppler echocardiography in asymptomatic intravenous heroin users

Am J Cardiol

(1992)

L.M. Baddour et al.

Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association

Circulation

(2015)

N.T. Olsen et al.

Prosthetic valve endocarditis after transcatheter aortic valve implantation

Circ Cardiovasc Interv

(2015)

I.J. Amat-Santos et al.

Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry

Circulation

(2015)

Agency for Healthcare Research and Quality

Overview of the national (nationwide) inpatient sample (NIS)

(2018)

Cited by (14)

Infective Endocarditis—Update for the Perioperative Clinician
2023, Journal of Cardiothoracic and Vascular Anesthesia
Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considerations for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.
Infective Endocarditis After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review
2023, Journal of the American College of Cardiology
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.
The evolution of polyurethane heart valve replacements: How chemistry translates to the clinic
2022, Materials Today Communications
Citation Excerpt :
Compared with MHVs, bioprosthetic valves obtained from animal tissue are considerably softer and more flexible, offering leaflet movements that resemble native heart valves [33–38]. However, bioprosthetic valves are prone to calcification, tissue failure, adverse inflammatory responses, and variable durability, particularly in younger patients [39–47], while transcatheter BHVs have been known to be susceptible to infection [48–50]. Moreover, BHVs cannot be customized to adopt the specific anatomy of patients as their specifications (e.g., thickness distribution, shape) are set by their biological donors [51,52].
Current heart valve replacements (HVRs) fail to comprehensively capture the physiological behavior of native heart valve tissues, allowing the burden of valvular heart disease to persist after surgical intervention. Through extensive research and clinical experience, it has become evident that material selection is central to the success of HVRs. One outstanding candidate material for next-generation HVRs is polyurethane. These polymers exhibit a unique segmented chemical structure that can imitate the mechanical strength and elasticity of soft biological tissues. Consequently, polyurethanes have long been investigated as HVR materials, however, progression to clinical utility has historically been impaired by the material’s susceptibility to biodegradation and calcification. This review presents a concise and critical analysis of past and recent investigations to elucidate the contemporary potential of polyurethane HVRs. Importantly, the overwhelming clinical failure of past prototypes necessitated a detailed examination to validate any further use of polyurethanes in HVR development. Recently, advancements in polyurethane chemistry have contributed towards addressing the shortcomings of polyurethane HVRs, encouraging progress towards clinical translation.
Commentary: Prescribe two antiplatelet drugs and receive fewer calls for Staphylococcus aureus–induced prosthetic endocarditis
2021, Journal of Thoracic and Cardiovascular Surgery
Incidence, Predictors, and Outcomes of Endocarditis After Transcatheter Aortic Valve Replacement in the United States
2020, JACC: Cardiovascular Interventions
Citation Excerpt :
Follow-up of endocarditis readmissions occurred through December 2017, providing a minimum follow-up period of 60 days for all patients. We identified the microbial organisms of endocarditis using validated ICD-9 and ICD-10 codes that were utilized in prior studies (Supplemental Table 1) (16–18). Based on the time of occurrence of endocarditis after the index TAVR admission, patients were classified into 3 groups—very early (≤30 days), early (31 days to 1 year), and late (>1 year) endocarditis—following definitions previously described (11).
This study sought to evaluate the incidence and outcomes of endocarditis after transcatheter aortic valve replacement (TAVR).
Data about endocarditis after TAVR are limited.
The study investigated Medicare patients who underwent TAVR from 2012 to 2017 and identified patients admitted with endocarditis during follow-up using a validated algorithm. The main study outcome was all-cause mortality.
Of 134,717 patients who underwent TAVR, 1868 patients developed endocarditis during follow-up (incidence 0.87%/year), with majority of infections (65.0%) occurring within 1 year. Incidence of endocarditis declined in recent years. The most common organisms were Staphylococcus (22.0%), Streptococcus (20.0%), and Enterococcus (15.5%). Important predictors for endocarditis were younger age at TAVR, male sex, prior endocarditis, end-stage renal disease, repeat TAVR procedures, liver and lung disease, and post-TAVR acute kidney injury. Thirty-day and 1-year mortality were 18.5% and 45.6%, respectively. After adjusting for comorbidities and procedural complications, endocarditis after TAVR was associated with 3-fold higher risk of mortality (44.9 vs. 16.2 deaths per 100 person-years; adjusted hazard ratio [aHR]: 2.94; 95% confidence interval [CI]: 2.77 to 3.12; p < 0.0001). End-stage renal disease (aHR: 2.12; 95% CI: 1.72 to 2.60), endocarditis complicated by cardiogenic shock (aHR: 2.50, 95% CI: 1.56 to 4.02), ischemic stroke (aHR: 1.56; 95% CI: 1.07 to 2.28), intracerebral hemorrhage (aHR: 1.67; 95% CI: 1.01 to 2.76), acute kidney injury (aHR: 1.44; 95% CI: 1.27 to 1.63), blood transfusion (aHR: 1.28; 95% CI: 1.09 to 1.50), staphylococcal (aHR: 1.71; 95% CI: 1.49 to 1.97), and fungal endocarditis (aHR: 1.72; 95% CI: 1.23 to 2.39) (p < 0.05 for all) portended higher mortality following endocarditis.
The incidence of endocarditis after TAVR is low and declining. However, it is associated with poor prognosis with one-half the patients dying within 1 year.
Infective endocarditis in patients who have undergone transcatheter aortic valve implantation: a review
2020, Clinical Microbiology and Infection
Citation Excerpt :
The Fig. S1 shows the selection process of the included studies (Fig. S1). TAVI-IE is defined as early IE (IE related to THV within 12 months after TAVI) or late IE (IE > 12 months from TAVI) [19,20]. In-hospital IE subsequent to TAVI was investigated in a US cross-sectional study of the National Inpatient Sample database where 120 of 41 025 patients (0.3%) developed IE during hospitalization for TAVI leading to higher rates of death (20.8% vs. 4.1%, p < 0.001) [19].
Transcatheter aortic valve implantation (TAVI) has been approved for the treatment of severe aortic stenosis since 2008 and recent trials have shown that TAVI is at least non-inferior to surgical aortic valve replacement (SAVR) with regards to short-term efficacy and safety in patients across all surgical risk profiles. Prosthetic valve endocarditis of the transcatheter heart valve is a feared complication; data on the risk of infective endocarditis (IE) subsequent to TAVI are now gradually emerging.
We set forth to conduct a review of the incidence, diagnosis, microbial aetiologies, prevention, outcome and management of TAVI-IE.
From the MEDLINE database we included a total of 12 observational studies and five studies of long-term results from randomized controlled trials.
The incidence of TAVI-IE was reported to be between 0.7% and 3.0% per person-year. The most common microbes were reported to be enterococci, Staphylococcus aureus, streptococci and coagulase-negative staphylococci. International guidelines on prevention strategies of IE recommend good sanitary conditions including cutaneous care, good oral hygiene and good care of dialysis catheters. Antibiotic prophylaxis is recommended by guidelines prior to dental procedures in patients with TAVI; however, evidence is sparse. The majority of the patients included in this review with TAVI-IE had an indication for surgical intervention due to IE (50.0% or more); however, only a small subset of the patients underwent surgery (16.4% or less). The in-hospital mortality was around 25%, i.e. of the same order of magnitude as in prosthetic valve IE in general, but varied substantially between studies (from 11% to 64%).
The US Food and Drug Administration's approval of TAVI in patients at low surgical risk may change the characteristics of patients with TAVI, which may influence the incidence, management, and outcome of patients with TAVI-IE.

View all citing articles on Scopus

View full text

In-hospital infective endocarditis following transcatheter aortic valve replacement: a cross-sectional study of the National Inpatient Sample database in the USA

Summary

Background

Aim

Methods

Findings

Conclusion

Section snippets

Background

Data source and study population

Results

Discussion

Conflict of interest statement

Funding sources

Lancet

JACC Cardiovasc Intervent

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Chron Dis

Mayo Clin Proc

J Am Coll Cardiol

J Am Dent Assoc

Can J Cardiol

J Am Coll Cardiol

Am J Cardiol

Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association

Circulation

Prosthetic valve endocarditis after transcatheter aortic valve implantation

Circ Cardiovasc Interv

Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry

Circulation

Overview of the national (nationwide) inpatient sample (NIS)