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Valve replacement resulting in endocarditis may occur in congenital heart disease
Endocarditis after transcatheter pulmonary valve replacement in children and adults with postoperative congenital heart disease in the right ventricular outflow tract was an important adverse outcome after the procedure, according to a study published in the Journal of the American College of Cardiology.
“Given the prevalence of mitigating and predisposing conditions and the high risk of endocarditis in this population overall, efforts to educate patients and caregivers about risk and about best practices for risk reduction are essential to reducing endocarditis rates after [transcatheter pulmonary valve replacement],” Doff B. McElhinney, MD, professor of cardiothoracic surgery and pediatrics at Stanford University Medical Center, and colleagues wrote.
Transcatheter pulmonary valve implantation
Researchers analyzed data from 309 patients (mean age, 18 years; 66% male) who underwent a transcatheter pulmonary valve implantation (Melody TPV, Medtronic) in the right ventricular outflow tract. Follow-up was conducted until transcatheter pulmonary valve explantation, death or completion of prescribed follow-up duration, whichever occurred first, for a median of 5.1 years and 1,660.3 patient-years of total observation.
During follow-up, 46 patients were diagnosed with endocarditis a median of 3.1 years after transcatheter pulmonary valve replacement, and 35 patients developed endocarditis related to the transcatheter pulmonary valve.
The incidence rate of endocarditis per year was 3.1% per patient-year. The annual incidence rate for transcatheter pulmonary valve-related endocarditis was 2.4% per patient-year.
At 5 years, the estimated freedom from an endocarditis diagnosis was 89% (95% CI, 85-93), and freedom from a transcatheter pulmonary valve-related endocarditis diagnosis was 92% (95% CI, 89-95).
Potential factors
Factors associated with the development of endocarditis was being aged 12 years or younger at implantation (HR = 2.3; 95% CI, 1.2-4.4) and an invasively measured post-implant peak gradient of at least 15 mm Hg (HR = 2.7; 95% CI, 1.4-4.9). These two factors were also associated with the development of transcatheter pulmonary valve-related endocarditis (aged 12 years: HR = 2.8; 95% CI, 1.3-5.7; gradient 15 mm Hg; HR = 2.6; 95% CI, 1.3-5.2).
“Ultimately, ongoing efforts to understand, prevent and optimize management of this complication will be paramount in making the best use of [transcatheter pulmonary valve] therapy,” McElhinney and colleagues wrote.
“The authors have increased our understanding of [infective endocarditis] of the valve,” William R. Davidson Jr., MD, director of the program for adult congenital heart disease at the Heart and Vascular Institute at Pennsylvania State University College of Medicine, and Ada C. Stefanescu Schmidt, MD, MSc, research fellow in medicine at Massachusetts General Hospital, wrote in a related editorial. “A serious hemodynamic syndrome has been better described, but new questions have been raised. Rapid application of new techniques to treat congenital heart disease is often justified by urgent need and the lack of sufficient patients for large trials. This approach has not consistently benefited patients. Years may be necessary to place a therapy in its proper place in the therapeutic armamentarium.” – by Darlene Dobkowski
Disclosures: The study was supported by Medtronic. McElhinney reports he served as a proctor and consultant for Medtronic. Davidson and Stefanescu Schmidt report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.