p.54 抽出テキスト

A number of studies have shown that cardiac surgery positively affects the clinical outcome of IE patients. Nevertheless, old age, comorbidities, and previous non-cardiac and cardiac procedures lead to surgical hesitancy by referring physicians, surgeons, and patients themselves.642 Moreover, these characteristics also influence the outcome of this fragile cohort.400,433 As a result, less frequent performance of curative surgery and increased mortality are typical hallmarks of IE episodes in elderly as compared with the younger population.640 In a recently published Swedish propensity analysis of IE patients from 2006 to 2017, the authors found that surgery was underused in the elderly and that 1-year mortality was significantly higher in elderly patients who did not undergo surgery.641 In a sub-analysis of the ESC EORP EURO-ENDO registry, the indication for surgery was less often recognized (51% vs. 57%) and surgery was far less frequently performed when indicated (35% vs. 68%) in patients >80 vs. <80 years. However, mortality of surgically treated patients was remarkably similar in patients <80 and >80 years after propensity matching (19.7% vs. 20.0%). Age was also not demonstrated to be an independent predictor of mortality in this large prospective study.640,643 These findings suggest that performance of surgery in well-selected elderly patients is underutilized and may increase their chance of survival. In elderly IE patients, functional and nutritional status are important predictors of outcomes.400 When considering cardiac surgery in elderly patients, functional and nutritional status, and their associated risks, should be accurately explored through a comprehensive assessment by geriatricians. In addition, the earliest possible discharge home to facilitate the patient’s functional recovery should be considered in this subgroup of patients.

12.3 Transcatheter prosthetic valve

endocarditis 12.3.1. Endocarditis following transcatheter aortic valve implantation The incidence of IE post-TAVI ranges from 0.3 to 1.9 per 100 patientyears,94,623,644–648 which is similar to that reported following surgical aortic valve replacement in both observational studies and RCTs.94,623,646,647 One recent study, however, reported a lower incidence of PVE after TAVI compared with surgical prostheses.649 The risk of IE is higher within the first year following the procedure, and particularly within the initial 3 months.644,645,648,650–652 A modest decrease in the incidence of IE post-TAVI has been observed in recent years, particularly in the early period following the procedure, presumably related to multiple technical improvements, more streamlined procedures, and a reduction of periprocedural complications.650,652 A similar IE rate has been reported irrespective of transcatheter valve type,653 and predisposing factors, including younger age, male gender, renal dysfunction, and significant residual aortic regurgitation, have been identified.94,644–646,648,651,652

12.3.1.1 Diagnosis

The diagnosis of IE post-TAVI is challenging. The stent frame of transcatheter valves, with a much higher amount of metal surrounding the valve leaflets compared with surgical prostheses, and the characteristics of TAVI patients (frequently elderly with multiple co-morbidities) may increase the diagnostic challenges in this population. The clinical presentation is frequently atypical, with fever lacking in 13–20% of patients.623,645,650 Enterococci and S. aureus are the two most common microorganisms involved in IE post-TAVI, followed by streptococci and CoNS.644–646,650 Some important aspects should be considered regarding TOE in patients with suspected IE post-TAVI: (i) no vegetations are detected in 38–60% of cases;623,645,650,651 (ii) vegetations are located in the stent frame of the transcatheter valve (and not on the valve leaflets) in 12% of cases, and this rate increases up to 19% in the presence of some self-expanding valve systems with a longer stent frame occupying the ascending aorta;653 and (iii) the vegetations are located outside the transcatheter valve in about one-third of cases, mainly at the level of the mitral valve.645,650,651 Nuclear imaging or CT have been useful to diagnose IE post-TAVI.654,655 The addition of [18F]FDG-PET/CT and/or CTA to the diagnostic work-up of IE in TAVI changed the final clinical diagnosis in 33% of patients.655 Intracardiac echocardiography may also be useful for detecting vegetations in patients with suspected IE after TAVI and negative TOE.165

12.3.1.2 Prognosis and treatment

Prognosis and treatment of post-TAVI PVE is complicated by the fact that patients are older and have more co-morbidities than post-surgical PVE patients. About two-thirds of patients with IE post-TAVI exhibit at least one complication, with acute kidney injury and HF being the most frequent adverse events.645,646,656 The in-hospital and 30-day mortality rates are very high, ranging from 16% to 36%,623,644–647,657 and increase up to 41–59% at 1-year follow-up.644,645,652,657 A higher patient risk profile, S. aureus, and the occurrence of IE complications have been identified as risk factors for increased mortality.645,652,657 Antimicrobial therapy for IE post-TAVI is similar to that of PVE (see Section 7). Similar to surgical PVE, cardiac surgery is considered the best option in the presence of IE complications, particularly severe prosthetic failure or HF, but is infrequently performed. Surgery is performed in ∼20% of cases (ranging from 3.8% to 31.3%),645,652,656 a much lower rate compared with NVE and surgical PVE. The characteristics of the TAVI population, with often advanced age and high or prohibitive surgical risk, along with the potential difficulties associated with the removal of some transcatheter valve systems (particularly those with a large amount of stent frame, frequently adherent to the ascending aorta after a few months following the TAVI procedure) may play a role in the low rate of surgical interventions. To date, all studies but one failed to demonstrate the potential benefit of surgery in IE post-TAVI patients,442,645,652,656,658 but the relatively small sample size of the studies and the multiplicity of potential confounders when comparing to those patients not receiving surgical treatment precludes definite conclusions. The only study showing a beneficial effect of surgical intervention focused on those patients who had a local extension of the infection (i.e. abscess or fistula).442 The decision to proceed with surgery in IE post-TAVI patients should be individualized, balancing the surgical risks and the prognosis of medical treatment alone. In cases with local extension of the infection, surgery may be recommended in the absence of a prohibitive surgical risk. In cases with healed IE and valve prosthesis dysfunction, repeat transcatheter therapy (valve-in-valve procedure) can be performed in select patients.659 Such interventions should be performed at least 1–3 months after the healed endocarditis episode and following a negative follow-up TOE.

12.3.2 Endocarditis following transcatheter

pulmonary valve implantation The incidence of IE post-transcatheter pulmonary valve implantation (TPVI) ranges from 1.6 to 4.0 per 100 patient-years,93,660–667 which seems to be higher than that reported following surgical pulmonary valve interventions (observational studies, no randomized data).662,663,667,668 While some studies suggest a higher risk associated with the use of bovine jugular vein valves,662,667,669 a recent large multicentre study including different transcatheter valve systems did not

ESC Guidelines                                                                                                                                                                                          4001

Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026