Download Transcatheter aortic-valve endocarditis confirmed by

Transcatheter Aortic-Valve Endocarditis Confirmed by Transesophageal
Echocardiography
Mathias Orban, Daniel Sinnecker, Helmut Mair, Michael Nabauer, Christian Kupatt, Christoph
Schmitz, Steffen Massberg, Karl-Ludwig Laugwitz and Petra Barthel
Circulation. 2013;127:e265-e266
doi: 10.1161/CIRCULATIONAHA.112.109033
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Images in Cardiovascular Medicine
Transcatheter Aortic-Valve Endocarditis Confirmed by
Transesophageal Echocardiography
Mathias Orban, MD; Daniel Sinnecker, MD; Helmut Mair, MD; Michael Nabauer, MD;
Christian Kupatt, MD; Christoph Schmitz, MD; Steffen Massberg, MD;
Karl-Ludwig Laugwitz, MD; Petra Barthel, MD
A
70-year-old white man was admitted to the Department
of Vascular Surgery with a critical right forearm ischemia
caused by acute thromboembolic occlusion and underwent
operative embolectomy. Microbiological testing revealed colonization of the embolus with Staphylococcus lugdunensis and
S. epidermidis. Because of pain in the lower thoracic spine, elevated C-reactive protein, and a recent history of spondylodiscitis with evidence of coagulase-negative Staphylococcus spp.,
the patient was transferred to the Department of Neurosurgery
16 days after vascular surgery. S. epidermidis was then isolated
from blood cultures. The patient had a history of coronary heart
disease with reduced left ventricular function, atrial fibrillation,
diabetes mellitus, and hemodialysis resulting from diabetic
nephropathy, as well as kidney transplantation and subsequent
kidney transplant failure in 2000. The patient was taking no
immunosuppressive medication at admission. He had had a
transcatheter aortic valve (CoreValve, Medtronic) implanted
12 months before as a result of severe native valve stenosis
(logistic EuroSCORE, 33.11% at the time of implantation).
He was transferred to our echocardiography laboratory with
persistently elevated levels of C-reactive protein. Three months
before transthoracic and transesophageal echocardiography
(Movies I and II in the online-only Data Supplement), he was
negative for signs of prosthetic valve endocarditis (PVE).
Two- and 3-dimensional transesophageal echocardiography now showed an elongated mass 3 cm in length floating
around a longitudinal axis within the stent lumen of the prosthetic valve. Apparently, the mass was attached to the stent
struts. In addition, there were signs of a paravalvular abscess
at the noncoronary sinus (Figure 1 and Movies III through
V in the online-only Data Supplement). Minor paravalvular regurgitation was present at the left coronary sinus. The
native valves did not show any signs of endocarditic lesions.
The peak velocity across the valve had increased by ≈140 cm/s
(Figure 2). After echocardiographic diagnosis of PVE and
initiation of calculated antibiotic therapy with vancomycin,
gentamicin, and rifampicin, the patient was transferred to
the Department of Cardiac Surgery. The infected valve was
replaced by a porcine valve (Hancock II, Medtronic; diameter 25 mm) under extracorporeal circulation. Intraoperative
findings confirmed massive lesions on the biological parts
of the transcatheter valve consistent with PVE (Figure 3).
Surprisingly, 3 to 4 stent struts had penetrated the aortic sinotubular junction close to the noncoronary sinus. The valve was
Figure 1. Two-dimensional transesophageal echocardiogram of prosthetic valve endocarditis after transcatheter aortic valve replacement. Two-dimensional transesophageal echocardiography (A, long axis; B, short axis) showing a 3-cm floating endocarditic lesion within
the stent lumen of a prosthetic transcatheter aortic valve (solid arrow). Signs of a paravalvular abscess can be seen close to the noncoronary sinus Valsalva (dashed arrow). Transesophageal images were obtained with a Philips X7-2t transducer/iE33 ultrasound system on
admission and a Siemens Acuson Sequoia ultrasound system 3 months before. Ao indicates aortic root; LA, left atrium; LV, left ventricle;
and RA right atrium.
From Deutsches Herzzentrum München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität MünchenDeutsches Herzzentrum
München and Medizinische Klinik I, Klinikum rechts der Isar, Technische Universität München (M.O., D.S., S.M., K.L.-L., P.B.); Department of Cardiac
Surgery, Klinikum der Universität München (H.M., D.S.); and Medizinische Klinik und Poliklinik I, Klinikum der Universität München (M.N., C.K.),
Munich, Germany. Drs Orban and Massberg are now at Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
112.109033/-/DC1.
Correspondence to Mathias Orban, MD, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistrasse 15, 81377
Munich, Germany. E-mail [email protected]
(Circulation. 2013;127:e265-e266.)
© 2013 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.112.109033
Downloaded from http://circ.ahajournals.org/ ate265
Universitaetsbibliothek LMU on October 30, 2014
e266 Circulation January 15, 2013
Figure 2. Two-dimensional transesophageal echocardiogram with transvalvular continuous-wave Doppler in the absence and presence
of prosthetic valve endocarditis. Two-dimensional transthoracic echocardiography with continuous-wave Doppler measurement 3 months
before (left) and on admission (right). The transvalvular peak velocity increased from ≈200 to 342 cm/s. Transthoracic images were
obtained with a Siemens Acuson Sequoia (left) and a Philips IE33 (right) ultrasound system, respectively.
colonized by multiresistent coagulase-negative Staphylococcus
spp. The patient was extubated on the day of surgery and discharged after 2 weeks.
There are only a few case reports of PVE after transcatheter
aortic-valve replacement (TAVR). Cases of PVE on a transapical aortic valve (Edward Sapien) with Enterococcus faecalis1
and a transfemoral aortic valve (CoreValve) with S. lugdunensis2 were lethal and showed unusual shape and localization
of the vegetations with complicating fistulas between the left
ventricular outflow tract and the right or left atrium. The latter
case report also described a mobile vegetation attached to the
prosthetic stent. So far, 2 cases have been successfully treated
medically.3,4 In a 3-year follow-up cohort of 70 patients undergoing TAVR who were declined surgical aortic valve replacement, 1 patient developed PVE.5 The 2-year rates of PVE in
the Placement of Aortic Transcatheter Valve Trial (PARTNER)
comparing TAVR (348 patients) and conventional surgical
aortic valve replacement in high-risk patients who were still
candidates for TAVR (351 patients) were comparable (4 versus 3 patients).6
To the best of our knowledge, this is one of the first reports
of a definite bacterial PVE on a transfemoral aortic valve confirmed by echocardiography and treated successfully with
cardiac surgery. Two- and 3-dimensional echocardiography
showed unusual position of the large vegetation within the
stent lumen. Whether these echocardiographic findings are
common for PVE after TAVR has to be further elucidated.‍
Disclosures
None
References
Figure 3. Intraoperative findings of the explanted aortic valve
prosthesis. The prosthetic transcatheter aortic valve was
removed during surgical aortic valve replacement. The stent
struts penetrating the sinotubular junction distal to the noncoronary sinus were cut through (dashed arrows) to release the valve.
Endocarditic material can be seen on the porcine pericardial leaflets (solid arrow).
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