David Del Val1, Mohamed Abdel-Wahab2, Norman Mangner3, Eric Durand4, Nikolaj Ihlemann5, Marina Urena6, Costanza Pellegrini7, Francesco Giannini8, Tomasz Gasior9, Wojtek Wojakowski10, Martin Landt11, Vincent Auffret12, Jan Malte Sinning13, Asim N Cheema14, Luis Nombela-Franco15, Chekrallah Chamandi16, Francisco Campelo-Parada17, Erika Munoz-Garcia18, Howard C Herrmann19, Luca Testa20, Kim Won-Keun21, Juan Carlos Castillo22, Alberto Alperi23, Didier Tchetche24, Antonio L Bartorelli25, Samir Kapadia26, Stefan Stortecky27, Ignacio Amat-Santos28, Harindra C Wijeysundera29, John Lisko30, Enrique Gutiérrez-Ibanes31, Vicenç Serra32, Luisa Salido33, Abdullah Alkhodair34, Ugolino Livi35, Tarun Chakravarty36, Stamatios Lerakis37, Victoria Vilalta38, Ander Regueiro39, Rafael Romaguera40, Utz Kappert9, Marco Barbanti41, Jean-Bernard Masson42, Frédéric Maes43, Claudia Fiorina44, Antonio Miceli45, Susheel Kodali46, Henrique B Ribeiro47, Jose Armando Mangione48, Fabio Sandoli de Brito49, Guglielmo Mario Actis Dato50, Francesco Rosato51, Maria-Cristina Ferreira52, Valter Correia de Lima53, Alexandre Siciliano Colafranceschi54, Alexandre Abizaid49, Marcos Antonio Marino55, Vinicius Esteves56, Julio Andrea57, Roger R Godinho58, Fernando Alfonso59, Helene Eltchaninoff4, Lars Søndergaard5, Dominique Himbert6, Oliver Husser60, Azeem Latib61, Hervé Le Breton12, Clement Servoz17, Isaac Pascual23, Saif Siddiqui24, Paolo Olivares25, Rosana Hernandez-Antolin33, John G Webb34, Sandro Sponga35, Raj Makkar36, Annapoorna S Kini62, Marouane Boukhris42, Philippe Gervais1, Axel Linke3, Lisa Crusius3, David Holzhey63, Josep Rodés-Cabau64. 1. Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada. 2. Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Heart Center, Segeberger Kliniken, Bad Segeberg, Germany. 3. Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany. 4. Normandie Univ, UNIROUEN, U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France. 5. Righospitalet, Copenhagen, Denmark. 6. Bichat Hôpital, Paris, France. 7. Deutsches Herzzentrum München, Munich, Germany. 8. Ospedale San Raffaele, Milan, Italy; Maria Cecilia Hospital, GVM Care and Research, Cotignola RA, Italy. 9. Herzzentrum Dresden, Technische Universität Dresden, Dresden, Germany. 10. Medical University of Silesia, Katowice, Poland. 11. Heart Center, Segeberger Kliniken, Bad Segeberg, Germany. 12. Univ Rennes, CHU Rennes, Inserm, LTSI - UMR1099, F 35000 Rennes, France. 13. Heart Center Bonn, Bonn, Germany. 14. St Michaels Hospital, Toronto, Ontario, Canada; Southlake Hospital, Newmarket, Ontario, Canada. 15. Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain. 16. Hôpital Européen Georges-Pompidou, Paris, France. 17. Hôpital Rangueil, Toulouse, France. 18. Hospital Universitario Virgen de la Victoria, Malaga, Spain. 19. Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. 20. IRCCS Pol. San Donato, Milan, Italy. 21. Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany. 22. Hospital Universitario Reina Sofia, Cordoba, Spain. 23. Hospital Universitario Central de Asturias, Oviedo, Spain. 24. Clinique Pasteur, Toulouse, France. 25. Centro Cardiologico Monzino, IRCCS and Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy. 26. Cleveland Clinic, Cleveland, Ohio, USA. 27. Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (on behalf of Swiss TAVI). 28. CIBERCV, Hospital Clínico Universitario de Valladolid, Valladolid, Spain. 29. Sunnybrook Health Science Center, Toronto, Ontario, Canada. 30. Emory University School of Medicine, Atlanta, Georgia, USA. 31. Instituto de Investigación Universitaria Gregorio Marañón, Hospital Gregorio Marañon, Madrid, Spain. 32. Hospital Vall d'Hebron, Barcelona, Spain. 33. Hospital Universitario Ramón y Cajal, Madrid, Spain. 34. St Paul's Hospital, Vancouver, British Columbia, Canada. 35. University Hospital of Udine, Udine, Italy. 36. Cedars-Sinai Heart Institute, Los Angeles, California, USA. 37. Emory University School of Medicine, Atlanta, Georgia, USA; Mount Sinai Hospital, New York, New York, USA. 38. Hospital Germans Trias i Pujol, Badalona, Spain. 39. Hospital Clínic de Barcelona, Barcelona, Spain. 40. Hospital de Bellvitge, L'Hospitalet de Llobregat, Spain. 41. A.O.U. Policlinico Vittorio Emanuele, University of Catania, Catania, Italy. 42. Centre Hospitalier de l'Université de Montreal, Montreal, Quebec, Canada. 43. Cliniques Universitaires Saint-Luc, Brussels, Belgium. 44. ASST-Spedali Civili di Brescia, Brescia, Italy. 45. Istituto Clinico Sant'Ambrogio, Milan, Italy; University Hospital Galway, Galway, Ireland. 46. Columbia University Medical Center, New York, New York, USA. 47. InCor, Heart Institute, University of São Paulo Medical School, Sao Paulo, Brazil; Hospital Samaritano Paulista, Sao Paulo, Brazil. 48. Hospital Beneficencia Portuguesa, Sao Paulo, Brazil. 49. InCor, Heart Institute, University of São Paulo Medical School, Sao Paulo, Brazil. 50. Ospedale Mauriziano, Torino, Italy. 51. Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy. 52. Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil. 53. Hospital São Francisco-Santa Casa de Porto Alegre, Porto Alegre, Brazil. 54. Hospital Pró-cardíaco, Rio de Janeiro, Brazil. 55. Hospital Madre Teresa, Belo Horizonte, Brazil. 56. Hospital Sao Luiz, Sao Paulo, Brazil. 57. Clínica Sao Vicente, Rio de Janeiro, Brazil. 58. Hospital Samaritano Paulista, Sao Paulo, Brazil. 59. Hospital Universitario La Princesa, Madrid, Spain. 60. Deutsches Herzzentrum München, Munich, Germany; St.-Johannes-Hospital, Dortmund, Germany. 61. Ospedale San Raffaele, Milan, Italy; Montefiore Medical Center, New York, New York, USA. 62. Mount Sinai Hospital, New York, New York, USA. 63. Heart Center Leipzig at University of Leipzig, Leipzig, Germany. 64. Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain. Electronic address: josep.rodes@criucpq.ulaval.ca.
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.
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.