European Heart Journal - Case Reports (2023) 7, 1–5 CASE REPORT https://doi.org/10.1093/ehjcr/ytad166 Valvular heart disease Transcatheter aortic valve replacement for acute aortic regurgitation due to Staphylococcus aureus infective endocarditis complicated with a perivalvular abscess: a case report Rosa Vila-Olives 1, Gerard Oristrell 1,2 *, Pau Rello 1 , and Núria Fernández-Hidalgo 3,4,5 1 Cardiology Department, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; 2Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER CV), Instituto de Salud Carlos III, 28029 Madrid, Spain; 3Infectious Department, Vall d’Hebron University Hospital, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain; 4Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain; and 5Universitat Autònoma de Barcelona, 08193 Barcelona, Spain Received 10 October 2022; first decision 2 December 2022; accepted 3 April 2023; online publish-ahead-of-print 12 April 2023 Background Infective endocarditis is a life-threatening disease associated with high mortality. Appropriate antimicrobial treatment and car­ diac surgery, when indicated, are closely related to prognosis. When cardiac surgery is contraindicated, prognosis worsens dra­ matically. There is few data concerning the use of transcatheter aortic valve replacement after healed aortic valve endocarditis or during active IE. We present the first case report of a transcatheter aortic valve replacement implanted during antimicrobial therapy for a severely symptomatic acute aortic regurgitation due to an infective endocarditis complicated with a perivalvular abscess. ............................................................................................................................................................................................. Case summary A 68-year-old man was admitted due to left hemiparesis and fever. An acute ischaemic stroke with haemorrhagic transform­ ation was diagnosed. Blood cultures were positive for methicillin-susceptible Staphylococcus aureus and a transoesophageal echocardiogram revealed an aortic endocarditis with an acute severe aortic regurgitation and a perivalvular abscess. Urgent cardiac surgery was contraindicated due to intracranial haemorrhage. However, the patient developed refractory pulmonary oedema and haemodynamic instability. Despite the perivalvular abscess, a transcatheter aortic valve replacement was suc­ cessfully performed 15 days after the diagnosis. Nine months after completing antimicrobial therapy, there were no signs of relapse. ............................................................................................................................................................................................. Discussion Transcatheter aortic valve replacement could be considered in selected patients with symptomatic severe aortic regurgitation due to aortic infective endocarditis during antimicrobial therapy when cardiac surgery is contraindicated. -Keywords -------------------------------------------------------------------------------------------------------------------------------------------------------------- Case report • Infective endocarditis • TAVR • Aortic valve endocarditis • Perivalvular abscess • Staphylococcus aureus -ESC - - - - - -Curriculum -------------------------------------------------------------------------------------------------------------------------------------------------------- 4.1 Aortic regurgitation • 4.11 Endocarditis • 6.4 Acute heart failure • 7.1 Haemodynamic instability • 4.10 Prosthetic valves * Corresponding author. Tel: (+34) 93 274 61 34, Fax: (+34) 93 274 60 34, Email: gerard.oristrell@gmail.com Handling Editor: Faten Yahia Peer-reviewers: Julio Echarte; Kashan Ali Compliance Editor: Hikmet Kadioglu Supplementary Material Editor: Siddhartha Mohan © The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 2 R. Vila-olives et al. Learning points • Prompt recognition and treatment of peripheral vein phlebitis and catheter-related bacteraemia is crucial to prevent infective endocarditis. • Infective endocarditis is associated with increased morbidity and mortality. In cases of intracranial haemorrhage, cardiac surgery should be postponed for at least four weeks. • Transcatheter aortic valve replacement could be considered in selected patients with active aortic infective endocarditis and severe haemo­ dynamic compromise secondary to severe aortic regurgitation, as a palliative solution or as a bridge to open-heart surgery once blood cul­ tures have become negative. pulmonary oedema. Violaceous nodules were also found on the Introduction pads of the fingers. Infective endocarditis (IE) is associated with high rates of mortality and A 12-lead electrocardiogram showed sinus tachycardia, PR interval morbidity. Staphylococcus aureus is the most frequently isolated micro­ of 200 ms, narrow QRS complex with no signs of acute ischaemia organism, and the one most frequently associated with neurological (Figure 1). Laboratory exams demonstrated normocytic anaemia, abso­ complications.1–3 More than 70% of patients of left-sided IE have indi­ lute neutrophil count of 7700 mm3, C-reactive protein of 29 mg/dL cation for cardiac surgery, but only 50% are finally operated on. One of (normal 0–0.5 mg/dL), normal renal function, and normal lactate levels the main reasons for rejecting a cardiac surgery is the high surgical risk.4 (<2 mmol/L). Two sets of blood cultures were collected. A cerebral Patients with surgery-indicated-IE but not undergoing cardiac surgery computed tomography (CT) showed hypodense areas in the right oc­ have an increased mortality rate, especially those with heart failure.5 cipital lobe, medial temporal lobe, and thalamus consistent with a re­ A few data exist concerning the use of transcatheter aortic valve re­ cent right posterior cerebral artery (PCA) stroke. Supportive care placement (TAVR) after healed aortic valve endocarditis or during ac­ was started. tive IE. We report the first case of aortic valve endocarditis On the second day of admission, the patient had sudden onset global complicated with severely symptomatic acute aortic regurgitation and aphasia with decreased consciousness level, requiring urgent intubation a perivalvular abscess in which a TAVR was successfully implanted dur­ and mechanical ventilation. A new cranial CT revealed an acute ischae­ ing antimicrobial therapy. mic infarct in the left middle cerebral artery, as well as a left frontal lobe haemorrhage and a haemorrhagic transformation of the established PCA stroke (Figure 2). Respiratory status deteriorated dramatically due to severe pulmonary oedema. Methicillin-susceptible S. aureus Timeline was isolated from blood cultures, and a transoesophageal echocardio­ gram (TEE) revealed thickened and phlegmonous aortic valve leaflets with a central perforation causing an acute severe regurgitation, and a perivalvular abscess (Figure 3, Supplementary material online, Videos 1–2). Left ventricular ejection fraction was preserved. Definite IE was Two weeks before admission Peripheral vein phlebitis diagnosed according to modified Duke criteria, and 2 g of cefazoline/ Admission Ischaemic stroke 8 h was started, which cleared the bacteraemia within two days. Two days after admission Intracranial bleeding and diagnosis of IE However, the patient presented an unfavourable course with haemo­ Two weeks after admission TAVR dynamic instability, worsening renal function and refractory pulmonary Sixteen weeks after TAVR Reduction of perivalvular thickening. oedema despite inotropic drugs and continuous renal replacement Negative blood cultures therapy. The case was discussed in the endocarditis team meeting. End of antibiotic therapy Neurological status was difficult to assess since the patient was intu­ One, four and sixteen weeks after Negative blood cultures bated and haemodynamically unstable. Cardiac surgery was considered the end of antibiotic contraindicated for at least four weeks because of intracranial haemor­ rhage. However, after starting cefazoline, the patient remained without Nine months after the end of No signs of relapse in the last fever and blood cultures were repeatedly negative. Then, although the antibiotic follow-up persistence of a perivalvular abscess, a TAVR MyValve of 32 mm was implanted two weeks after admission to improve haemodynamic situ­ ation and as a bridge to open-heart surgery if neurological status al­ lowed it. After TAVR, no conduction disturbance or paravalvular leaks were documented and the patient could be successfully weaned Case report from ventilation and inotrope drugs. Unfortunately, after sedation with­ A 68-year-old man was admitted due to syncope and weakness. His drawal, neurological sequelae became apparent, especially behavioural past medical history included hypertension and dyslipidaemia. Two disturbances, and cardiac surgery was ruled out. weeks before the admission, he had been hospitalized for a Subsequently, antibiotic treatment was maintained, and the patient SARS-CoV2 pneumonia complicated with a cephalic vein phlebitis. did not present new episodes of fever. Likewise, TEE monitoring was No blood cultures were performed, and it was treated with levo­ performed to guide duration of antibiotic treatment. Sixteen weeks floxacin and linezolid for five days. On admission, blood pressure after TAVR, a TEE showed a normal bioprosthetic aortic valve was 158/77 mmHg and heart rate was 126 beats per minute. (Supplementary material online, Video 3) and a significant reduction of Temperature was 39.5 Celsius and oxygen saturation was 96% on the perivalvular thickening compared to initial exploration (Figure 4), 2 L of supplementary oxygen. Neurological examination revealed and cefazoline was stopped. However, despite the persistence of a peri­ left hemianopsia, anosognosia, and left hemiparesis and hemisen­ prosthetic thickening, follow-up blood cultures a week, a month, and sory loss. Cardiopulmonary auscultation showed a third heart four months after completing antibiotic remained negative. Currently, sound associated with a sistodiastolic murmur and signs of at nine months follow-up, he persists with no signs of relapse. Transcatheter aortic valve replacement for acute aortic regurgitation due to Staphylococcus aureus 3 Figure 1 Electrocardiogram with sinus rhythm, a PR interval of 200 ms and narrow QRS complex. Figure 2 Computed tomography scan showed ischaemic infarcts in the left middle cerebral artery (A) and right posterior cerebral artery (B); as well as a left frontal lobe haemorrhage (C, arrowhead) and an incipient haemorrhagic transformation of the posterior cerebral artery stroke (C, arrow). Discussion failure.5 However, in some cases, cardiac surgery is not performed due to a high surgical risk, leaving us with no further therapeutic options. To the best of our knowledge, this is the first case report in which a Although new-generation TAVR has demonstrated safety and feasi­ TAVR was implanted in a patient with active aortic IE complicated bility when used in patients with pure aortic regurgitation,8 current with perivalvular abscess. Previously, a few cases of TAVR implanted guidelines do not consider the use of TAVR in cases of IE, since it in the setting of an active IE have been reported in the literature,6–7 does not allow physical removal of infected material and perivalvular tis­ but none of them had peri-annular complication. Current IE guidelines4 sue. However, recently, TAVR has shown to be a safe therapeutic alter­ recommend early surgery in patients who have heart failure, perivalvular native for residual valvular lesions after successfully healed endocarditis.9 abscess or severe prosthetic valve dysfunction. Mortality is high if these In our case, the patient had a S. aureus IE with severe aortic regurgi­ conditions are not treated surgically, especially in patients with heart tation causing a critical haemodynamic and respiratory condition 4 R. Vila-olives et al. Figure 3 A transoesophageal echocardiogram showed thickened and phlegmonous aortic valve leaflets with a perivalvular abscess in long-axis view (left) and short-axis view (right). Diameter of aortic root was 40 and 27 mm in sinus of Valsalva. Figure 4 Mid-esophageal aortic valve long-axis view (left) and short-axis view (right) 1 month (A) and 4 months after transcatheter aortic valve re­ placement (B). Of note, the improvement of the perivalvular thickening during follow-up. Transcatheter aortic valve replacement for acute aortic regurgitation due to Staphylococcus aureus 5 despite optimal medical therapy. Moreover, he presented a peri- Patient consent: The patient did not have mental capacity to con­ annular aortic abscess, but blood cultures were repeatedly negative un­ sent to publication, so written consent was obtained from the patient’s der antimicrobial therapy. An open-heart surgery was prohibitive due wife in accordance with COPE guidelines. to prior intracranial bleeding and neurological status was uncertain. Despite the high risk of local active infection,10 we performed TAVR Conflict of interest: None declared. to improve haemodynamic situation as a bridge to open-heart surgery. Fortunately, the patient not only improved from a haemodynamic point Funding: The authors declare that they have not received funding for of view, but also did not present evidence of uncontrolled infection or the publication of the article. relapse during follow-up. The duration of antimicrobial treatment was broadly discussed in the Data availability Endocarditis Team and guided by TEE monitoring. After observing a sig­ The data underlying this article are available in the article and in its on­ nificant improvement in the perivalvular thickening four months after line supplementary material. TAVR, cefazoline was discontinued. Although the patient could be con­ sidered at a high risk of relapse due to peri-annular abscess and S. aureus infection, no clinical signs of relapse were documented at nine months References follow-up. Unfortunately, the patient persisted with neurological dis­ 1. Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr, Bayer AS, et al. Clinical pres­ entation, etiology, and outcome of infective endocarditis in the 21st century: the abilities that could not have been predicted in the acute phase. International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern In conclusion, TAVR could be considered in selected patients with Med 2009;169:463–473. active IE and severe haemodynamic compromise secondary to severe 2. 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