The Evolving Risk of Infective Endocarditis After Transcatheter Aortic Valve Implantation.

Objectives: Despite increased use of transcatheter aortic valve implantation (TAVI) in older adults with severe aortic stenosis, contemporary data on infective endocarditis (IE)-an infrequent but serious complication-are lacking. This study addresses this gap in knowledge.

Methods: We analysed 280 073 Medicare beneficiaries who underwent TAVI between 2013 and 2022. The primary outcome was the change in the 1-year incidence rate of IE post-TAVI. Joinpoint regression was used to evaluate the trend in the IE incidence as annual percent change (APC). Adjusted Cox models were used to evaluate associations between IE incidence and patient characteristics, as well as 12-month outcomes.

Results: The incidence rate of IE 1 year post-TAVI decreased from 20.0/1000 person-years in 2013 to 13.1/1000 in 2021. There was no change in incidence between 2013 and 2018 but a significant decline thereafter (-12.1% [CI, -20.7% to -7.5%], P < .001). This decline was associated with the decrease in non-elective TAVI (sub-distribution hazard ratio: 0.98 [CI, 0.94-0.99], P < .001); 4.8% of patients with IE underwent aortic valve reintervention. The 30-day aortic valve reintervention rate after IE increased significantly from 2013 to 2022 (APC: 24.9% [CI, 17.2%-33.0%], P < .001). The 30-day mortality rate after TAVI explant was 9.3%; the adjusted risk of death declined over time (HR: 0.73 [CI, 0.58-0.92], P = .01). However, the overall 30-day risk-adjusted mortality rate of TAVI-IE remained unchanged.

Conclusions: The post-TAVI incidence of IE in Medicare patients decreased after 2019. This decrease was associated with declining rates of non-elective TAVI and coincided with FDA approval of TAVI for low-risk patients. TAVI explant rates were low but increased recently. The lack of improvement in 30-day mortality underscores the challenges of elderly care after TAVI.