Case Presentation: A 77-year-old male with a history of systolic heart failure, aortic stenosis (AS) status post transcatheter aortic valve replacement (TAVR) 5 months prior, chronic kidney disease, and type 2 diabetes mellitus was brought to the emergency room after a fall at home. He started experiencing a pain on his chronic right great toe ulcer 5 days prior, but denied other symptoms including fever or chills. His vital signs revealed temperature of 40.4 degree Celsius, blood pressure of 98/47 mmHg, heart rate of 131 beats per minute. The physical exam was only notable for warmth and erythema on his right foot with a small ulcer and minimal discharge on his right great toe. No heart murmur was heard. The remarkable tests included WBC of 12.7, stable creatinine at 1.22 mg/dL, and glucose of 209 mg/dL. Computed tomography of the right lower leg showed evidence of chronic osteomyelitis. He was admitted for the cellulitis and osteomyelitis of the right foot on broad-spectrum antibiotics. While his cellulitis did improve, blood cultures continued to identify MRSA for 9 days despite IV antibiotics. Vascular surgery recommended investigating other uncontrolled infectious sources. Transthoracic echocardiology was unrevealing, while Transesophageal echocardiology on the day 7 confirmed a vegetation on the aortic prosthetic valve. Cardiology and cardiac surgery recommended no surgical intervention as he was deemed a poor surgical candidate. He was discharged to a skilled nursing facility on IV Vancomycin, Ceftaroline, and oral Rifampin for 6 weeks. The antibiotic regimen was changed to oral rifampin and doxycycline for suppressive therapy afterwards.
Discussion: TAVR has been increasingly used for intermediate to high risk patients with AS who previously had no treatment option as the indications for TAVR has been expanding. As a result, hospitalists will likely encounter infectious endocarditis (IE) after TAVR. IE after TAVR can be triggered by urinary tract/lung infection, endoscopic procedure, or even dental procedure without prophylaxis. In our case, toe infection was the likely portal of entry. More important, those who needed TAVR would not be good surgical candidates in the first place as was our case who had multiple risk factors including chronic osteomyelitis, diabetes, and poor cardiac functions. The treatment option will be limited to intravenous antibiotics in many cases, but the data are currently scant with regards to surgical versus medical management of IE after TAVR. In one analysis of small pooled data, the mortality in IE after TAVR was not significantly different between surgical and medical treatments (survival at 6 months: 65.6% vs. 61.5%).
Conclusions: IE after TAVR requires multidisciplinary decision making with cardiology, cardiac surgery, and infectious disease. Hospitalists should be aware of the available outcome data to guide the extensive discussion with the patients. Unless new data come out, medical management may provide equal outcomes compared to the surgery.