Emergent Off-Label TAVR for Native Aortic Valve Endocarditis

Keywords: TAVR, aortic valve endocarditis

A 76-year-old-male transferred to our center with severe breathlessness (New York Heart Association III-IV). On examination, he was afebrile, hypoxic, and tachycardic with a wide pulse-pressure (blood pressure, 110/40 mm Hg). Chest auscultation revealed a systolic and early diastolic murmur. Two weeks prior to admission, he reported severe cellulitis treated with intravenous antibiotics (flucloxacillin).

Transthoracic echocardiogram (TTE) demonstrated severe aortic valve (AoV) stenosis and evidence of AoV disruption with mobile vegetations and severe aortic regurgitation (AR) in keeping with plausible infectious endocarditis (IE) (Figures 1A-1D).

Following 3 sets of blood cultures, the patient commenced treatment with intravenous antibiotics (initially with vancomycin and gentamycin that were subsequently changed to amoxicillin) and diuretics. Blood cultures were negative, likely due to previous treatment with antibiotics. Due to the acute decompensation, he underwent early heart team discussion with a view to urgent surgical AoV replacement. The patient was deemed high risk for surgery (liver cirrhosis and frailty) with a consensus for off-label transcatheter aortic valve replacement (TAVR) with a cerebral protection device (CPD) due to large mobile vegetation. Transfemoral TAVR was uncomplicated and a 26-mm Sapien 3-Ultra bioprosthesis (Edwards LifeSciences) was deployed with CPD (Figure 1E). Subsequent examination of the CPD showed large vegetation fragments (Figures 1F-1G). Post TAVR, there was an increase in diastolic blood pressure (Figure 1H) and TTE showed well-functioning bioprosthesis. The patient successfully recovered, with no evidence of stroke, and was discharged 2 weeks later following a period of intensive rehabilitation. Histological examination of the vegetation fragments did not reveal any pathogens. The patient had a full 6-week treatment with intravenous antibiotics with full clearance of the infection. Following a period of intensive rehabilitation with physiotherapy, the patient was successfully discharged with an increased package of care at home as he was living alone. At his 3-month follow-up, he remained asymptomatic, and a repeat echo showed a well-seated and functioning AoV bioprosthesis with no AR and a mean gradient of 17 mm Hg.

TAVR with cerebral protection might be a safe treatment-option in inoperable patients with AoV IE.

Affiliations and Disclosures

From the ¹Department of Cardiology, St Thomas’ Hospital, London, United Kingdom; and ²Department of Cardiology, Mitera General Hospital, Hygeia Healthcare Group, Athens, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Redwood reports proctor and speaker fees from Edwards Lifesciences. Dr Prendergast reports unrestricted research and educational grants from Edwards Lifesciences; speaker and consultancy fees from Abbott Vascular, Anteris, and Edwards Lifesciences. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 13, 2022.

Address for correspondence: Andreas Kalogeropoulos, MD, PhD, FRCP, FESC, Department of Cardiology, Mitera General Hospital Hygeia Healthcare Group, Athens, Greece. Email: andkalog@gmail.com

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