Stoke occurs in 10% of patients developing infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR), according to a new analysis of registry data that identifies and outlines multiple risk factors.
The findings, published online Monday and in the May 11 issue of the Journal of the American College of Cardiology, also suggest that occurrence of stroke is associated with increased in-hospital and 1-year mortality rates.
A number of factors including overall history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation, were found to increase risk of stroke in IE patients, said the authors, who noted that stroke risk increased relative to the number of risk factors a patient had.
Led by David del Val, MD, from the Quebec Heart & Lung Institute, the team behind the study noted that stroke is one of the most common and potentially disabling complications of IE.
However, they warned that “scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR)”.
The new analysis utilized data from the Infectious Endocarditis after TAVR International Registry, including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).
A total of 57 patients (10%) had a stroke during IE hospitalization, with no differences in causative microorganism between groups, said the team – adding that S-IE patients displayed higher rates of acute renal failure, systemic embolization and persistent bacteremia (p < 0.05 for all).
The vast majority of patients were treated with antibiotics alone, and no differences were observed in the overall surgical treatment comparing S-IE (22.8%) and NS-IE (19.1%) patients (p = 0.508), said del Val and colleagues.
However, patients with stroke had “ominous prognosis,” according to the authors, with higher in-hospital mortality than patients without stroke (S-IE: 54.4% vs. NS-IE: 28.7%; difference, 25.7; 95% confidence interval [CI]: 12.2 to 39.2; p < 0.001). Overall mortality rate at 1 year was also higher in S-IE versus NS-IE patients (66.3% vs. 45.6%; p < 0.001 by log-rank test).
Independent determinants of stroke complicating IE post-TAVR were found to be: any history of previous stroke before IE episode, use of balloon-expandable valves, residual aortic regurgitation >2 after TAVR, very early IE (within 30 days), and vegetation size >8 mm, said the team.
Furthermore, it was found that risk of stroke was increased with each additional risk factor. Incidence of stroke in patients with none of the above risk factors was 3.1% (95% CI: 1.1% to 8.6%), while incidence in patients with between one and four risk factors was 6.1% (95% CI: 3.7% to 9.9%), 13.1% (95% CI: 8.9% to 18.8%), 28.9% (95% CI: 17.7% to 43.4%), and 60% (95% CI: 23.1% to 88.2%), respectively.
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).
An accompanying editorial led by Vuyisile T. Nkomo, MD, MPH, of the Mayo Clinic, noted that the study is the first to examine stroke as a complication of IE in a large multicenter cohort and highlights the “devastating consequences” of IE after TAVR and the “even worse consequences” when IE was associated with stroke.
The editorialist noted that TAVR has revolutionized the treatment of aortic stenosis and is currently moving toward less complex and younger patients with lower surgical risk.
“Despite the unequivocal advances in the safety and periprocedural complications of TAVR, IE with and without stroke in this TAVR population remains a dreadful complication,” they wrote.
Further, they warned that while the incidence of IE and stroke is “relatively low” after TAVR, the number of procedures is expected to grow exponentially, “increasing the number of patients at risk of developing this life-threatening complication.”
“This points to the critical importance of efforts at prevention of IE with appropriate antibiotic prophylaxis and addressing potential sources of infection, for example, dental screening, before invasive cardiac procedures,” said Nkomo and colleagues.
They concluded that del Val et al. are “commended for their large-scale effort at quantifying and characterizing stroke as a complication of IE following TAVR,” and suggested that further multicenter registries, including contemporary and lower-risk cohorts, will be critical to address some unanswered questions, and will complement the novel observations from the current study.
del Val D, Abdel-Wahab M, Mangner N, et al. Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2021;77: 2276-87.
Nkomo VT, DeSimone DC, Miranda WR. Stroke Associated With Infective Endocarditis After Transcatheter Aortic Valve Replacement Is Devastating. J Am Coll Cardiol 2021;77: 2288-90.
Image Source: https://commons.wikimedia.org/wiki/File:Aortic_valve_endocarditis_with_vegetation_E00121_(CardioNetworks_ECHOpedia).jpg