|Year : 2020 | Volume
| Issue : 2 | Page : 31-32
Antibiotic prophylaxis in the transcatheter aortic valve implantation era
Robin Razmi1, Joseph V Pergolizzi2, Jo Ann LeQuang2, Peter Magnusson3
1 Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle; Department of Medical Sciences, Infectious Medicine, Uppsala University, Uppsala, Sweden
2 NEMA Research Inc., Naples, Florida, USA
3 Centre for Research and Development, Region Gävleborg/Uppsala University, Gävle; Department of Medicine, Cardiology Research Unit, Karolinska Institute, Stockholm, Sweden
|Date of Submission||21-Oct-2019|
|Date of Acceptance||23-Apr-2020|
|Date of Web Publication||13-Jul-2020|
Dr. Robin Razmi
Infektionsmottagningen, Gävle Sjukhus, 80324 Gävle
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Razmi R, Pergolizzi JV, LeQuang JA, Magnusson P. Antibiotic prophylaxis in the transcatheter aortic valve implantation era. Heart Mind 2020;4:31-2
The procedure of transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of symptomatic aortic stenosis in the last few decades. Its lower invasiveness when compared to surgical aortic valve replacement (SAVR) has made it the procedure of choice in high-risk patients. Moreover, a recent meta-analysis of available data has established a mortality benefit in TAVI patients irrespective of procedural risk. Hence, TAVI is expected to account for an increasing proportion of aortic valve implantations going forward. This is certainly a beneficial development, particularly for individuals who have been deemed too frail to undergo open surgery. However, the increasing numbers of valve prostheses in high-risk patients, i.e., with severe comorbidity, imply a high risk of complications. One of the most detrimental complications is prosthetic valve infective endocarditis (PVE). The severity of infection in this setting motivates a renewed discussion on the controversial subject of endocarditis prophylaxis.
Despite the lower invasiveness of the surgical procedure, patients undergoing TAVI have been shown to have a similar incidence of PVE when compared to SAVR patients, with a yearly rate of 1.9% compared to 1.7% in SAVR (relative risk 1.09; 95% confidence interval 0.96–1.23; P = 0.17). Furthermore, analyses of propensity-matched cohorts have shown no significant difference in PVE risk in comparable individuals, regardless of the implantation method used. However, the in-hospital mortality in the TAVI group has proven to be higher than in any other infective endocarditis subgroup, around 47%. While the reasons for the higher mortality have not been entirely elucidated, it has been postulated that the high average frailty of TAVI patients is a main driver; indeed, many times, the TAVI procedure was chosen because of comorbidities that constitute a SAVR contraindication. Comorbidities, such as degenerative valve disease, kidney failure, and diabetes constitute risk for infective endocarditis, as well as for a worse outcome. Assuming that the initial SAVR contraindications persist, this would also disqualify these patients for adjunctive surgical PVE therapy. Another possible explanation for the high incidence and poor prognosis is the larger amount of prosthetic material in transcatheter-implanted valves. It has also been observed that crimping of the valve during the implantation process may cause leaflet damage, in turn increasing the likelihood of PVE.
The causative agents in PVE do not differ significantly in patients who have undergone TAVI when compared to those who have undergone SAVR. In both cohorts, bacteria of the Staphylococcus species dominate, accounting for around half of the detected causative agents, and split evenly between the more virulent Staphylococcus aureus and the less virulent coagulase-negative staphylococci. Other important causative agents are enterococci and alpha-hemolytic streptococci. The latter are significant due to their natural colonization of the human oral cavity, and their tendency to translocate to the bloodstream in small or large gingival trauma.
Antibiotic prophylaxis in dental procedures has been a controversial topic in recent decades. While initial prophylactic policies were generous, the indications were tightened due to a lack of evidence supporting a wider use of prophylaxis. This aligns with a general trend of more restrictive antibiotic policies, implemented due to a growing awareness of the drugs' side effects, including antibiotic resistance. Criticisms have been leveled at the restrictive policy, pointing to the fact that the incidence of infective endocarditis has indeed increased since the turn of the millennium. Proponents of said policies, meanwhile, have pointed to the fact that this is part of a wider trend of an aging population, more comorbidities, and a cumulatively greater number of risk factors on a population level, including an increasing prevalence of prosthetic valves. There is also a lack of data as to what extent the increase can be attributed to oral streptococci covered by the amoxicillin prophylaxis. The current guidelines from the European Society of Cardiology suggest that prophylaxis be considered in high-risk dental procedures conducted in high-risk patients. The general use of prophylaxis prior to procedures concerning the respiratory, gastrointestinal, or genitourinary tract is not recommended. Patients considered at high risk are the following three categories: (A) patients with previous infective endocarditis, (b) patients with an untreated cyanotic congenital heart disease, and (c) patients with any prosthetic valve, including transcatheter-implanted prostheses and homografts.
As we are now expected to enter an era where TAVI increasingly becomes the dominant procedure for aortic valve implantation, increased vigilance is warranted. Patients with prosthetic valves of any kind are considered high-risk patients; patients who have received their prostheses through the TAVI procedure should be considered as particularly vulnerable due to their high mortality in infective endocarditis. Therefore, it is important to adhere to current prophylaxis policies. Increasing antibiotic resistance is a concern of utmost importance, emphasizing the need to reserve antibiotic use for only the strictest indications. In light of the potentially devastating consequences of PVE in TAVI patients, however, one could argue that the use of antibiotic prophylaxis in this vulnerable patient population would qualify as such an indication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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