Cardiac surgery offers no benefit over antibiotics alone in TAVR patients with infective endocarditis
Cardiac surgery doesn’t offer any benefit over medical treatment with antibiotics in transcatheter aortic valve replacement (TAVR) patients who have infective endocarditis (IE), researchers reported in the Journal of the American Heart Association this month.
Somewhere between 0.67 percent and 3.4 percent of TAVR patients will develop IE after their procedures, corresponding author Norman Mangner, MD, of Heart Center Dresden in Germany, and colleagues wrote in JAHA. And the prognosis isn’t positive, either—IE has been linked to an in-hospital mortality rate of 41.8 percent and a two-year mortality rate of 66.7 percent.
“Guidelines recommend early surgery to be performed in complicated cases of IE, including those with congestive heart failure, perivalvular complications and high risk of embolism,” Gilbert Habib, MD, PhD, said in an accompanying editorial. “Unfortunately, these recommendations cannot be applied in all patients with TAVR IE because contraindications to surgery frequently exist in this high-risk population.”
Mangner and his team overseas tested the efficacy of cardiac surgery with antibiotics versus antibiotic treatment alone in a small group of 64 patients. Twenty underwent surgery, while the remaining 44—who were more likely to have severe chronic kidney disease and a higher Society of Cardiac Thoracic Surgeons score—stuck to an antibiotics-only regimen.
Looking at a primary endpoint of one-year mortality, the authors said outcomes were similar between both study groups. Having an indication for surgery, presenting with sepsis or experiencing mitral regurgitation were associated with one-year mortality, but Habib said there still isn’t enough published data to prove one approach is more successful than the other.
Because of that, he said, it’s imperative doctors discuss treatment options with their individual patients, who likely vary in clinical status, operative risk and comorbidities.
“Further studies need to provide clear information to the clinicians about the optimal use of new imaging techniques to diagnose TAVR IE when it is suspected and the best way to treat it when the diagnosis is definite,” Habib wrote. “Pending the results of future studies, we should recognize that factors other than surgery mainly influence outcome in patients with TAVR IE.”
He said those factors can include anything from frailty to heart failure to renal problems. Mangner et al. said their study had limitations, including its small sample size.
“In this small, and therefore statistically limited, but high-risk patient cohort, cardiac surgery provided no significant mortality benefit compared with medical therapy,” they wrote. “Individual decision-making by a heart and endocarditis team is necessary to offer those patients the most reasonable treatment option.”
After graduating from Indiana University-Bloomington with a bachelor’s in journalism, Anicka joined TriMed’s Chicago team in 2017 covering cardiology. Close to her heart is long-form journalism, Pilot G-2 pens, dark chocolate and her dog Harper Lee.