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Observational Study
. 2021 May 11;77(18):2276-2287.
doi: 10.1016/j.jacc.2021.03.233.

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

David Del Val  1 , Mohamed Abdel-Wahab  2 , Norman Mangner  3 , Eric Durand  4 , Nikolaj Ihlemann  5 , Marina Urena  6 , Costanza Pellegrini  7 , Francesco Giannini  8 , Tomasz Gasior  9 , Wojtek Wojakowski  10 , Martin Landt  11 , Vincent Auffret  12 , Jan Malte Sinning  13 , Asim N Cheema  14 , Luis Nombela-Franco  15 , Chekrallah Chamandi  16 , Francisco Campelo-Parada  17 , Erika Munoz-Garcia  18 , Howard C Herrmann  19 , Luca Testa  20 , Kim Won-Keun  21 , Juan Carlos Castillo  22 , Alberto Alperi  23 , Didier Tchetche  24 , Antonio L Bartorelli  25 , Samir Kapadia  26 , Stefan Stortecky  27 , Ignacio Amat-Santos  28 , Harindra C Wijeysundera  29 , John Lisko  30 , Enrique Gutiérrez-Ibanes  31 , Vicenç Serra  32 , Luisa Salido  33 , Abdullah Alkhodair  34 , Ugolino Livi  35 , Tarun Chakravarty  36 , Stamatios Lerakis  37 , Victoria Vilalta  38 , Ander Regueiro  39 , Rafael Romaguera  40 , Utz Kappert  9 , Marco Barbanti  41 , Jean-Bernard Masson  42 , Frédéric Maes  43 , Claudia Fiorina  44 , Antonio Miceli  45 , Susheel Kodali  46 , Henrique B Ribeiro  47 , Jose Armando Mangione  48 , Fabio Sandoli de Brito Jr  49 , Guglielmo Mario Actis Dato  50 , Francesco Rosato  51 , Maria-Cristina Ferreira  52 , Valter Correia de Lima  53 , Alexandre Siciliano Colafranceschi  54 , Alexandre Abizaid  49 , Marcos Antonio Marino  55 , Vinicius Esteves  56 , Julio Andrea  57 , Roger R Godinho  58 , Fernando Alfonso  59 , Helene Eltchaninoff  4 , Lars Søndergaard  5 , Dominique Himbert  6 , Oliver Husser  60 , Azeem Latib  61 , Hervé Le Breton  12 , Clement Servoz  17 , Isaac Pascual  23 , Saif Siddiqui  24 , Paolo Olivares  25 , Rosana Hernandez-Antolin  33 , John G Webb  34 , Sandro Sponga  35 , Raj Makkar  36 , Annapoorna S Kini  62 , Marouane Boukhris  42 , Philippe Gervais  1 , Axel Linke  3 , Lisa Crusius  3 , David Holzhey  63 , Josep Rodés-Cabau  64
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Free article
Observational Study

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

David Del Val et al. J Am Coll Cardiol. .
Free article

Abstract

Background: Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).

Objectives: The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.

Methods: Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).

Results: A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).

Conclusions: Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.

Keywords: TAVR; infective endocarditis; prosthetic valve endocarditis; stroke; transcatheter aortic valve implantation.

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Conflict of interest statement

Funding Support and Author Disclosures Dr. del Val was supported by a research grant from the Fundación Alfonso Martin Escudero (Madrid, Spain). Dr. Mangner has received personal fees from Edwards Lifesciences, Medtronic, Biotronik, Novartis, Sanofi Genzyme, AstraZeneca, Pfizer, and Bayer, outside of the submitted work. Dr. Husser has received personal fees from Boston Scientific; and has received payments from Abbott. Dr. Sinning has received speaker honoraria from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic; and has received research grants from Boston Scientific, Edwards Lifesciences, and Medtronic, outside of the submitted work. Dr. Won-Keun has received personal fees from Boston Scientific, Edwards Lifesciences, Abbott, Medtronic, and Meril, outside of the submitted work. Dr. Herrmann has received institutional research grants from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic; and has received consulting fees from Edwards Lifesciences and Medtronic. Dr. Stortecky has received grants to the institution from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; and has received personal fees from Boston Scientific, BTG, and Teleflex, outside of the submitted work. Dr. Tchetche has received consulting fees from Abbott Vascular, Boston Scientific, Edwards Lifesciences, and Medtronic. Dr. Webb has received consulting fees from Edwards Lifesciences and St. Jude Medical. Dr. Makkar has received research grants from Edwards Lifesciences, Medtronic, Abbott, Capricor, and St. Jude Medical; has served as a proctor for Edwards Lifesciences; and has received consulting fees from Medtronic. Dr. Lerakis has received consulting fees from Edwards Lifesciences. Dr. de Brito Jr. has received honoraria from Medtronic and Edwards Lifesciences for symposium speeches and proctoring cases. Dr. Le Breton has received lecture fees from Edwards Lifesciences, outside of the submitted work. Dr. Linke has received personal fees from Medtronic, Abbott, Edwards Lifesciences, Boston Scientific, AstraZeneca, Novartis, Pfizer, Abiomed, Bayer, and Boehringer, outside the submitted work. Dr. Rodés-Cabau holds the Research Chair “Fondation Famille Jacques Larivière” for the Development of Structural Heart Disease Interventions; and has received institutional research grants from Edwards Lifesciences, Medtronic, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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