Surgical management is associated with improved survival for endocarditis after transcatheter aortic valve replacement

Background: Prosthetic valve endocarditis is a rare yet devastating complication following transcatheter aortic valve replacement (TAVR). This study aims to investigate the outcomes of surgical versus medical management of post-TAVR endocarditis.
Methods: Between 2011 and 2024, 67 patients with post-TAVR endocarditis were identified, comprising 24 (35.8%) patients managed surgically and 43 (64.2%) managed medically. All cases were reviewed by our multidisciplinary endocarditis team to determine the optimal treatment strategy.
Results: The overall incidence of post-TAVR endocarditis was 1.4%. The number of endocarditis cases increased over time from 1–2 in 2015–2018 to 18 in 2023. The most frequent source of endocarditis was unknown (32.8%), and the predominant causative organism was enterococcus species (25.4%). Notably, among the 43 medically managed patients, 19 (44.2%) exhibited surgical indications, predominantly due to large vegetations with or without embolic complications (n=11; 57.9%). The medical management group had a higher proportion of females and more frequent use of self-expandable valves compared to the surgical group. The time interval between TAVR and endocarditis diagnosis was similar across both groups. In the surgically managed cohort, isolated aortic valve replacement was uncommon, with most patients undergoing complex TAVR explantations coupled with concomitant procedures, most frequently aortic root repair (n=11; 45.8%). The 30-day and 1-year mortality rates for the three groups (surgical, medical without surgical indications, and medical with surgical indications) were 0%, 4.2%, and 31.6% (P=0.002), and 4.2%, 20.8%, and 73.7% (P<0.001), respectively.
Conclusions: Surgical management was associated with significantly improved survival compared to medical management for post-TAVR endocarditis. The poor clinical outcomes in the medically managed group were primarily due to patients who did not undergo surgery despite having surgical indications. Prudent clinical judgment and timely surgical intervention when indicated are critical to enhancing the overall clinical outcomes of this challenging condition.