Infective Endocarditis After Melody Valve Implantation in the Pulmonary Position: A Systematic Review

Abstract

Background: Infective endocarditis (IE) after transcatheter pulmonary valve implantation (TPVI) in dysfunctioning right ventricular outflow tract conduits has evoked growing concerns. We aimed to investigate the incidence and the natural history of IE after TPVI with the Melody valve through a systematic review of published data.

Methods and results: PubMed, EMBASE, and Web of Science databases were systematically searched for articles published until March 2017, reporting on IE after TPVI with the Melody valve. Nine studies (including 851 patients and 2060 patient-years of follow-up) were included in the analysis of the incidence of IE. The cumulative incidence of IE ranged from 3.2% to 25.0%, whereas the annualized incidence rate ranged from 1.3% to 9.1% per patient-year. The median (interquartile range) time from TPVI to the onset of IE was 18.0 (9.0-30.4) months (range, 1.0-72.0 months). The most common findings were positive blood culture (93%), fever (89%), and new, significant, and/or progressive right ventricular outflow tract obstruction (79%); vegetations were detectable on echocardiography in only 34% of cases. Of 69 patients with IE after TPVI, 6 (8.7%) died and 35 (52%) underwent surgical and/or transcatheter reintervention. Death or reintervention was more common in patients with new/significant right ventricular outflow tract obstruction (69% versus 33%; P=0.042) and in patients with non-streptococcal IE (73% versus 30%; P=0.001).

Conclusions: The incidence of IE after implantation of a Melody valve is significant, at least over the first 3 years after TPVI, and varies considerably between the studies. Although surgical/percutaneous reintervention is a common consequence, some patients can be managed medically, especially those with streptococcal infection and no right ventricular outflow tract obstruction.

Keywords: Melody valve; congenital heart disease; endocarditis; percutaneous pulmonary valve implantation; percutaneous valve; pulmonary valve; transcatheter valve implantation.

Figure 1

Scatter plots of the cumulative (A) and annualized (B) incidence rate of infective endocarditis (IE) plotted against the sample size (number of patients) of the individual studies14, 15, 16, 17, 18, 19, 20, 21, 22 (Spearman correlation coefficient=−0.80 and −0.73, P=0.010 and P=0.025, respectively).

Figure 2

Scatter plots of the cumulative (A) and annualized (B) incidence rate of infective endocarditis (IE) plotted against the follow‐up duration (in months) of the individual studies14, 15, 16, 17, 18, 19, 20, 21, 22 (Spearman correlation coefficient=0.16 and −0.27, P>0.05 for both). Dot size is proportionate to the sample size (number of patients) of each study.

Figure 3

Scatter plots of the cumulative (A) and annualized (B) incidence rate of infective endocarditis (IE) plotted against the time period of patient enrollment of the individual studies14, 15, 16, 17, 18, 19, 20, 21, 22 (Spearman correlation coefficient=0.81 and 0.57, P=0.008 and P=0.11, respectively). Dots correspond to the middle of the enrollment time interval for each study, and dot size is proportionate to the sample size (number of patients) of each study. The characteristics of the 9 studies are summarized in Table 1.

Figure 4

A cumulative curve of the individual patients with Melody valve endocarditis displaying (on the horizontal axis) the time interval between transcatheter pulmonary valve implantation (TPVI) and the onset of infective endocarditis (IE). The figure represents data from 59 (of 69) patients in whom the exact time interval from TPVI to IE was reported.