Transcatheter Aortic-Valve Endocarditis Confirmed by Transesophageal Echocardiography
2013; Lippincott Williams & Wilkins; Volume: 127; Issue: 2 Linguagem: Inglês
10.1161/circulationaha.112.109033
ISSN1524-4539
AutoresMathias Orban, Daniel Sinnecker, Helmut Mair, Michael Näbauer, Christian Kupatt, Christoph Schmitz, Steffen Maßberg, Karl‐Ludwig Laugwitz, Petra Barthel,
Tópico(s)Infectious Aortic and Vascular Conditions
ResumoHomeCirculationVol. 127, No. 2Transcatheter Aortic-Valve Endocarditis Confirmed by Transesophageal Echocardiography Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBTranscatheter Aortic-Valve Endocarditis Confirmed by Transesophageal Echocardiography Mathias Orban, MD, Daniel Sinnecker, MD, Helmut Mair, MD, Michael Nabauer, MD, Christian Kupatt, MD, Christoph Schmitz, MD, Steffen Massberg, MD, Karl-Ludwig Laugwitz, MD and Petra Barthel, MD Mathias OrbanMathias Orban From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Daniel SinneckerDaniel Sinnecker From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Helmut MairHelmut Mair From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Michael NabauerMichael Nabauer From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Christian KupattChristian Kupatt From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Christoph SchmitzChristoph Schmitz From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Steffen MassbergSteffen Massberg From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. , Karl-Ludwig LaugwitzKarl-Ludwig Laugwitz From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. and Petra BarthelPetra Barthel From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.), Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. Originally published15 Jan 2013https://doi.org/10.1161/CIRCULATIONAHA.112.109033Circulation. 2013;127:e265–e266A 70-year-old white man was admitted to the Department of Vascular Surgery with a critical right forearm ischemia caused by acute thromboembolic occlusion and underwent operative embolectomy. Microbiological testing revealed colonization of the embolus with Staphylococcus lugdunensis and S. epidermidis. Because of pain in the lower thoracic spine, elevated C-reactive protein, and a recent history of spondylodiscitis with evidence of coagulase-negative Staphylococcus spp., the patient was transferred to the Department of Neurosurgery 16 days after vascular surgery. S. epidermidis was then isolated from blood cultures. The patient had a history of coronary heart disease with reduced left ventricular function, atrial fibrillation, diabetes mellitus, and hemodialysis resulting from diabetic nephropathy, as well as kidney transplantation and subsequent kidney transplant failure in 2000. The patient was taking no immunosuppressive medication at admission. He had had a transcatheter aortic valve (CoreValve, Medtronic) implanted 12 months before as a result of severe native valve stenosis (logistic EuroSCORE, 33.11% at the time of implantation). He was transferred to our echocardiography laboratory with persistently elevated levels of C-reactive protein. Three months before transthoracic and transesophageal echocardiography (Movies I and II in the online-only Data Supplement), he was negative for signs of prosthetic valve endocarditis (PVE). Two- and 3-dimensional transesophageal echocardiography now showed an elongated mass 3 cm in length floating around a longitudinal axis within the stent lumen of the prosthetic valve. Apparently, the mass was attached to the stent struts. In addition, there were signs of a paravalvular abscess at the noncoronary sinus (Figure 1 and Movies III through V in the online-only Data Supplement). Minor paravalvular regurgitation was present at the left coronary sinus. The native valves did not show any signs of endocarditic lesions. The peak velocity across the valve had increased by ≈140 cm/s (Figure 2). After echocardiographic diagnosis of PVE and initiation of calculated antibiotic therapy with vancomycin, gentamicin, and rifampicin, the patient was transferred to the Department of Cardiac Surgery. The infected valve was replaced by a porcine valve (Hancock II, Medtronic; diameter 25 mm) under extracorporeal circulation. Intraoperative findings confirmed massive lesions on the biological parts of the transcatheter valve consistent with PVE (Figure 3). Surprisingly, 3 to 4 stent struts had penetrated the aortic sinotubular junction close to the noncoronary sinus. The valve was colonized by multiresistent coagulase-negative Staphylococcus spp. The patient was extubated on the day of surgery and discharged after 2 weeks.Download figureDownload PowerPointFigure 1. Two-dimensional transesophageal echocardiogram of prosthetic valve endocarditis after transcatheter aortic valve replacement. Two-dimensional transesophageal echocardiography (A, long axis; B, short axis) showing a 3-cm floating endocarditic lesion within the stent lumen of a prosthetic transcatheter aortic valve (solid arrow). Signs of a paravalvular abscess can be seen close to the noncoronary sinus Valsalva (dashed arrow). Transesophageal images were obtained with a Philips X7-2t transducer/iE33 ultrasound system on admission and a Siemens Acuson Sequoia ultrasound system 3 months before. Ao indicates aortic root; LA, left atrium; LV, left ventricle; and RA right atrium.Download figureDownload PowerPointFigure 2. Two-dimensional transesophageal echocardiogram with transvalvular continuous-wave Doppler in the absence and presence of prosthetic valve endocarditis. Two-dimensional transthoracic echocardiography with continuous-wave Doppler measurement 3 months before (left) and on admission (right). The transvalvular peak velocity increased from ≈200 to 342 cm/s. Transthoracic images were obtained with a Siemens Acuson Sequoia (left) and a Philips IE33 (right) ultrasound system, respectively.Download figureDownload PowerPointFigure 3. Intraoperative findings of the explanted aortic valve prosthesis. The prosthetic transcatheter aortic valve was removed during surgical aortic valve replacement. The stent struts penetrating the sinotubular junction distal to the noncoronary sinus were cut through (dashed arrows) to release the valve. Endocarditic material can be seen on the porcine pericardial leaflets (solid arrow).There are only a few case reports of PVE after transcatheter aortic-valve replacement (TAVR). Cases of PVE on a transapical aortic valve (Edward Sapien) with Enterococcus faecalis1 and a transfemoral aortic valve (CoreValve) with S. lugdunensis2 were lethal and showed unusual shape and localization of the vegetations with complicating fistulas between the left ventricular outflow tract and the right or left atrium. The latter case report also described a mobile vegetation attached to the prosthetic stent. So far, 2 cases have been successfully treated medically.3,4 In a 3-year follow-up cohort of 70 patients undergoing TAVR who were declined surgical aortic valve replacement, 1 patient developed PVE.5 The 2-year rates of PVE in the Placement of Aortic Transcatheter Valve Trial (PARTNER) comparing TAVR (348 patients) and conventional surgical aortic valve replacement in high-risk patients who were still candidates for TAVR (351 patients) were comparable (4 versus 3 patients).6To the best of our knowledge, this is one of the first reports of a definite bacterial PVE on a transfemoral aortic valve confirmed by echocardiography and treated successfully with cardiac surgery. Two- and 3-dimensional echocardiography showed unusual position of the large vegetation within the stent lumen. Whether these echocardiographic findings are common for PVE after TAVR has to be further elucidated.DisclosuresNoneFootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.109033/-/DC1.Correspondence to Mathias Orban, MD, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistrasse 15, 81377 Munich, Germany. E-mail [email protected]References1. Carnero-Alcázar M, Maroto Castellanos LC, Carnicer JC, Rodríguez Hernández JE. Transapical aortic valve prosthetic endocarditis.Interact Cardiovasc Thorac Surg. 2010; 11:252–253.CrossrefMedlineGoogle Scholar2. Gotzmann M, Mügge A. Fatal prosthetic valve endocarditis of the CoreValve ReValving System.Clin Res Cardiol. 2011; 100:715–717.CrossrefMedlineGoogle Scholar3. Head SJ, Dewey TM, Mack MJ. Fungal endocarditis after transfemoral aortic valve implantation.Catheter Cardiovasc Interv. 2011; 78:1017–1019.CrossrefMedlineGoogle Scholar4. Huan Loh P, Bundgaard H, Søndergaard L. Infective endocarditis following transcatheter aortic valve replacement: diagnostic and management challenges [published online March 16, 2012 ahead of print].Catheter Cardiovasc Interv.doi:10.1002/ccd.24368.Google Scholar5. Gurvitch R, Wood DA, Tay EL, Leipsic J, Ye J, Lichtenstein SV, Thompson CR, Carere RG, Wijesinghe N, Nietlispach F, Boone RH, Lauck S, Cheung A, Webb JG. Transcatheter aortic valve implantation: durability of clinical and hemodynamic outcomes beyond 3 years in a large patient cohort.Circulation. 2010; 122:1319–1327.LinkGoogle Scholar6. Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, Fontana GP, Dewey TM, Thourani VH, Pichard AD, Fischbein M, Szeto WY, Lim S, Greason KL, Teirstein PS, Malaisrie SC, Douglas PS, Hahn RT, Whisenant B, Zajarias A, Wang D, Akin JJ, Anderson WN, Leon MB; PARTNER Trial Investigators. Two-year outcomes after transcatheter or surgical aortic-valve replacement.N Engl J Med. 2012; 366:1686–1695.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Calcaterra D, Harris K, Goessl M, Dasari G, Kaur N and Chavez I (2021) Findings of prosthetic valve endocarditis in the balloon-expandable trans-catheter aortic valve: review of the literature and tips of management, Journal of Cardiothoracic Surgery, 10.1186/s13019-021-01609-5, 16:1, Online publication date: 1-Dec-2021. Malvindi P, Luthra S, Sarvananthan S, Zingale A, Olevano C and Ohri S (2020) Surgical treatment of transcatheter aortic valve infective endocarditis, Netherlands Heart Journal, 10.1007/s12471-020-01494-y, 29:2, (71-77), Online publication date: 1-Feb-2021. Ibrahim A, Ahmed A, Kiernan T and Arnous S (2018) Early prosthetic valve endocarditis after transcatheter aortic valve implantation using St Jude Medical Portico valve, BMJ Case Reports, 10.1136/bcr-2018-225037, (bcr-2018-225037) Mylotte D, Andalib A, Theriault-Lauzier P, Dorfmeister M, Girgis M, Alharbi W, Chetrit M, Galatas C, Mamane S, Sebag I, Buithieu J, Bilodeau L, de Varennes B, Lachapelle K, Lange R, Martucci G, Virmani R and Piazza N (2014) Transcatheter heart valve failure: a systematic review, European Heart Journal, 10.1093/eurheartj/ehu388, 36:21, (1306-1327), Online publication date: 1-Jun-2015. Pericas J, Llopis J, Cervera C, Sacanella E, Falces C, Andrea R, Garcia de la Maria C, Ninot S, Vidal B, Almela M, Paré J, Sabaté M, Moreno A, Marco F, Mestres C and Miro J (2015) Infective endocarditis in patients with an implanted transcatheter aortic valve: Clinical characteristics and outcome of a new entity, Journal of Infection, 10.1016/j.jinf.2014.12.013, 70:6, (565-576), Online publication date: 1-Jun-2015. Amat-Santos I, Ribeiro H, Urena M, Allende R, Houde C, Bédard E, Perron J, DeLarochellière R, Paradis J, Dumont E, Doyle D, Mohammadi S, Côté M, San Roman J and Rodés-Cabau J (2015) Prosthetic Valve Endocarditis After Transcatheter Valve Replacement, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2014.09.013, 8:2, (334-346), Online publication date: 1-Feb-2015. Gallagher M (2015) Prosthetic Aortic Valves and Diagnostic Challenges Aortic Stenosis, 10.1007/978-1-4471-5242-2_10, (147-169), . Arain F, Williams B, Lick S, Boroumand N and Ahmad M (2013) Echocardiographic, Histopathologic, and Surgical Findings in Staphylococcus lugdunensis Mitral Valve Endocarditis After Prostate Biopsy, Circulation, 128:14, (e204-e206), Online publication date: 1-Oct-2013. Citro R, Mirra M, Baldi C, Prota C, Palumbo B, Piscione F and La Canna G (2013) Concomitant dynamic obstruction and endocarditis after "valve in valve" TAVI implantation, International Journal of Cardiology, 10.1016/j.ijcard.2013.03.018, 167:2, (e27-e29), Online publication date: 1-Jul-2013. January 15, 2013Vol 127, Issue 2 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.109033PMID: 23319815 Originally publishedJanuary 15, 2013 PDF download Advertisement SubjectsCardiovascular SurgeryCatheter-Based Coronary and Valvular InterventionsEchocardiographyInfectious EndocarditisValvular Heart Disease
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