Doff B McElhinney1, Yulin Zhang2, Jamil A Aboulhosn3, Brian H Morray4, Elżbieta Katarzyna Biernacka5, Athar M Qureshi6, Alejandro J Torres7, Shabana Shahanavaz8, Bryan H Goldstein9, Allison K Cabalka10, Holly Bauser-Heaton11, Stanimir Georgiev12, Felix Berger13, Oscar Millan-Iturbe14, Lynn F Peng2, Aimee K Armstrong15, Daniel S Levi16, Aneta Fronczak-Jakubczyk5, Lars Sondergaard17, Jason H Anderson10, Dietmar Schranz18, Thomas K Jones4, John P Cheatham19, Stephan Schubert20, Peter Ewert12. 1. Stanford University School of Medicine, Palo Alto, California, USA. Electronic address: doff@stanford.edu. 2. Stanford University School of Medicine, Palo Alto, California, USA. 3. David Geffen School of Medicine at UCLA, Los Angeles, California, USA. 4. Seattle Children's Hospital, University of Washington, Seattle, Washington, USA. 5. The Cardinal Stefan Wyszyński Institute of Cardiology, Warsaw, Poland. 6. Texas Children's Hospital, Houston, Texas, USA. 7. New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA. 8. Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA. 9. Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA. 10. Mayo Clinic College of Medicine, Rochester, Minnesota, USA. 11. Sibley Heart Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA. 12. German Heart Center, Munich, Germany. 13. Deutsches Herzzentrum Berlin, Berlin, Germany. 14. Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Centro Medico Nacional Siglo XXI, Mexico City, Mexico. 15. Nationwide Children's Hospital, Columbus, Ohio, USA. 16. Mattel Children's Hospital at UCLA, Los Angeles, California, USA. 17. Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark. 18. University Clinic Giessen, Giessen, Germany. 19. Centro Medico Nacional Siglo XXI, Mexico City, Mexico. 20. Deutsches Herzzentrum Berlin, Berlin, Germany; Ruhr University of Bochum, Bad Oeynhausen, Germany.
Abstract
BACKGROUND: Endocarditis has emerged as one of the most impactful adverse events after transcatheter pulmonary valve replacement (TPVR), but there is limited information about risk factors for and outcomes of this complication. OBJECTIVES: The purpose of this study was to evaluate risk factors for and outcomes of endocarditis in a large multicenter cohort. METHODS: The authors established an international registry focused on characterizing endocarditis after TPVR, including the incidence, risk factors, characteristics, and outcomes. RESULTS: Investigators submitted data for 2,476 patients who underwent TPVR between July 2005 and March 2020 and were followed for 8,475 patient-years. In total, 182 patients were diagnosed with endocarditis a median of 2.7 years after TPVR, for a cumulative incidence of 9.5% (95% CI: 7.9%-11.1%) at 5 years and 16.9% (95% CI: 14.2%-19.8%) at 8 years (accounting for competing risks: death, heart transplant, and explant) and an annualized incidence of 2.2 per 100 patient-years. Staphylococcus aureus and Viridans group Streptococcus species together accounted for 56% of cases. Multivariable analysis confirmed that younger age, a previous history of endocarditis, and a higher residual gradient were risk factors for endocarditis, but transcatheter pulmonary valve type was not. Overall, right ventricular outflow tract (RVOT) reintervention was less often to treat endocarditis than for other reasons, but valve explant was more often caused by endocarditis. Endocarditis was severe in 44% of patients, and 12 patients (6.6%) died, nearly all of whom were infected with Staphylococcus aureus. CONCLUSIONS: The incidence of endocarditis in this multicenter registry was constant over time and consistent with prior smaller studies. The findings of this study, along with ongoing efforts to understand and mitigate risk, will be critical to improve the lifetime management of patients with heart disease involving the RVOT. Although endocarditis can be a serious adverse outcome, TPVR remains an important tool in the management of RVOT dysfunction.
BACKGROUND: Endocarditis has emerged as one of the most impactful adverse events after transcatheter pulmonary valve replacement (TPVR), but there is limited information about risk factors for and outcomes of this complication. OBJECTIVES: The purpose of this study was to evaluate risk factors for and outcomes of endocarditis in a large multicenter cohort. METHODS: The authors established an international registry focused on characterizing endocarditis after TPVR, including the incidence, risk factors, characteristics, and outcomes. RESULTS: Investigators submitted data for 2,476 patients who underwent TPVR between July 2005 and March 2020 and were followed for 8,475 patient-years. In total, 182 patients were diagnosed with endocarditis a median of 2.7 years after TPVR, for a cumulative incidence of 9.5% (95% CI: 7.9%-11.1%) at 5 years and 16.9% (95% CI: 14.2%-19.8%) at 8 years (accounting for competing risks: death, heart transplant, and explant) and an annualized incidence of 2.2 per 100 patient-years. Staphylococcus aureus and Viridans group Streptococcus species together accounted for 56% of cases. Multivariable analysis confirmed that younger age, a previous history of endocarditis, and a higher residual gradient were risk factors for endocarditis, but transcatheter pulmonary valve type was not. Overall, right ventricular outflow tract (RVOT) reintervention was less often to treat endocarditis than for other reasons, but valve explant was more often caused by endocarditis. Endocarditis was severe in 44% of patients, and 12 patients (6.6%) died, nearly all of whom were infected with Staphylococcus aureus. CONCLUSIONS: The incidence of endocarditis in this multicenter registry was constant over time and consistent with prior smaller studies. The findings of this study, along with ongoing efforts to understand and mitigate risk, will be critical to improve the lifetime management of patients with heart disease involving the RVOT. Although endocarditis can be a serious adverse outcome, TPVR remains an important tool in the management of RVOT dysfunction.