Perivalvular Extension of Infective Endocarditis After Transcatheter Aortic Valve Replacement.

BACKGROUND: Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a dismal prognosis. However, scarce data exist on IE perivalvular extension (PEE) in such patients. METHODS: This multicenter study included 579 patients who had the diagnosis of definite IE at a median of 171 (53-421) days following TAVR. PEE was defined as the presence of an intracardiac abscess, pseudoaneurysm, or fistula. RESULTS: A total of 105 patients (18.1%) were diagnosed with PEE (perivalvular abscess, pseudoaneurysm, fistula, or a combination in 87, 7, 7, and 4 patients, respectively). A history of chronic kidney disease (adjusted odds ratio [ORadj], 2.08; 95% confidence interval [CI]: 1.27-3.41; P = .003) and IE secondary to coagulase-negative staphylococci (ORadj, 2.71; 95% CI: 1.57-4.69; P < .001) were associated with an increased risk of PEE. Surgery was performed at index IE episode in 34 patients (32.4%) with PEE (vs 15.2% in patients without PEE, P < .001). In-hospital and 2-year mortality rates among PEE-IE patients were 36.5% and 69.4%, respectively. Factors independently associated with an increased mortality were the occurrence of other complications (stroke post-TAVR, acute renal failure, septic shock) and the lack of surgery at index IE hospitalization (padj < 0.05 for all). CONCLUSIONS: PEE occurred in about one-fifth of IE post-TAVR patients, with the presence of coagulase-negative staphylococci and chronic kidney disease determining an increased risk. Patients with PEE-IE exhibited high early and late mortality rates, and surgery during IE hospitalization seemed to be associated with better outcomes.

15†W monolithic fiber laser at 3.55†µm.

We report a dual-wavelength-pumped all-fiber continuous-wave (CW) laser operating at 3.55 µm that reached an output power of 14.9 W, which is, to the best of our knowledge, a record. The laser cavity, made of an erbium-doped fluoride fiber and bounded by two fiber Bragg gratings (FBGs), operates at an overall optical efficiency of 17.2% and a slope efficiency of 51.3% with respect to the 1976 nm launched pump power. The all-fiber design of the cavity not only allows for significant power scaling of the laser output, but also improves its long-term stability at high output power. The cavity design was set according to a numerical optimization that showed very good agreement with the experimental results.

Impact of drug adherence on blood pressure response to alcohol-mediated renal denervation.

PURPOSE: While poor drug adherence is frequent in patients with resistant hypertension, detailed analyses of the impact of drug adherence on the success of renal denervation are scarce. We report drug adherence at baseline, changes in drug adherence, and the influence of these parameters on blood pressure changes at 6 and 12 months in patients treated with alcohol-mediated renal denervation as part of the Peregrine study. MATERIALS AND METHODS: Urinary detection of antihypertensive drugs was performed using high-performance liquid chromatography-tandem mass spectrometry. Full adherence, partial adherence, and complete non-adherence were defined as 0, 1, or ≥2 drugs not detected, respectively. RESULTS: Renal denervation was performed in 45 patients with uncontrolled hypertension on ≥3 antihypertensive medications (62% men, age 55 ± 10 years). At baseline, the proportion of fully, partially, and non-adherent patients was 62% (n = 28), 16% (n = 7), and 22% (n = 10), respectively. At 6 months, adherence improved by 21% (n = 9), remained unchanged at 49% (n = 21), and worsened by 30% (n = 13). Mean 24-h systolic blood pressure decreased by 10 ± 13, 10 ± 4, and 14 ± 19 mmHg in fully, partially, and non-adherent patients (p = 0.77), and by 14 ± 14, 8 ± 11, and 14 ± 18 mmHg in patients who improved, maintained, or decreased adherence, respectively (p = 0.35). The results at 12 months were similar. CONCLUSION: About 40% of patients with apparently treatment-resistant hypertension were not fully adherent at baseline, and adherence decreased further in 30%. Nevertheless, mean blood pressure changes after renal denervation were similar irrespective of drug adherence. Our results suggest that such patients may benefit from alcohol-mediated renal denervation, irrespective of drug adherence. These findings are hypothesis-generating and need to be confirmed in ongoing sham-controlled trials.

Temporal Trends, Characteristics, and Outcomes of Infective Endocarditis After Transcatheter Aortic Valve Replacement.

BACKGROUND: Procedural improvements combined with the contemporary clinical profile of patients undergoing transcatheter aortic valve replacement (TAVR) may have influenced the incidence and outcomes of infective endocarditis (IE) following TAVR. We aimed to determine the temporal trends, characteristics, and outcomes of IE post-TAVR. METHODS: Observational study including 552 patients presenting definite IE post-TAVR. Patients were divided in 2 groups according to the timing of TAVR (historical cohort [HC]: before 2014; contemporary cohort [CC]: after 2014). RESULTS: Overall incidence rates of IE were similar in both cohorts (CC vs HC: 5.45 vs 6.52 per 1000 person-years; P = .12), but the rate of early IE was lower in the CC (2.29‰ vs 4.89‰, P < .001). Enterococci were the most frequent microorganism. Most patients presented complicated IE ( CC: 67.7%; HC: 69.6%; P = .66), but the rate of surgical treatment remained low (CC: 20.7%; HC: 17.3%; P = .32). The CC exhibited lower rates of in-hospital acute kidney injury (35.1% vs 44.6%; P = .036) and in-hospital (26.6% vs 36.4%; P = .016) and 1-year (37.8% vs 53.5%; P < .001) mortality. Higher logistic EuroScore, Staphylococcus aureus etiology, and complications (stroke, heart failure, and acute renal failure) were associated with in-hospital mortality in multivariable analyses (P < .05 for all). CONCLUSIONS: Although overall IE incidence has remained stable, the incidence of early IE has declined in recent years. The microorganism, high rate of complications, and very low rate of surgical treatment remained similar. In-hospital and 1-year mortality rates were high but progressively decreased over time.

2.3 W monolithic fiber laser operating in the visible.

We report, to the best of our knowledge, the first monolithic visible fiber laser pumped by a pigtailed diode. The robust cavity design proposed is based on a highly reflective fiber Bragg grating spliced to a double-clad praseodymium-doped fiber. The laser signal generated at 635.5 nm is single-mode, has a FWHM bandwidth of 0.16 nm, and reaches a maximum cw output power of 2.3 W. This demonstration breaks ground for the development of reliable high-power visible fiber lasers.

Reduction of Lipid-Core Burden Index in Nonculprit Lesions at Follow-Up after ST-Elevation Myocardial Infarction: A Randomized Study of Bioresorbable Vascular Scaffold versus Optimal Medical Therapy.

BACKGROUND: Non-flow-limiting nonculprit lesions (NCL) that contain a large lipid-rich necrotic core (nonculprit lipid-rich plaques (NC-LRP)) are most likely to cause recurrent acute coronary syndrome after ST-elevation myocardial infarction (STEMI). Near-infrared spectroscopy (NIRS) detects LRPs using the maximum 4 mm lipid-core burden index (maxLCBI4 mm). Few data are available regarding NIRS-guided therapy of these NC-LRPs, which are a potential target for preventive stenting. Bioresorbable vascular scaffold (BVS) provides local drug delivery and could facilitate plaque passivation after resorption. This study sought to assess the safety of BVS implantation in NC-LRPs and its efficacy in reducing maxLCBI4 mm at 2-year follow-up after STEMI. METHODS AND RESULTS: In total, 33 non-flow-limiting NCLs from 29 STEMI patients were included in this study. Of these, 15 were LRPs and were randomly assigned to either the BVS + optimal medical therapy (OMT) arm (group 1; N = 7) or the OMT arm (group 2; N = 8). At baseline, there were no differences in plaque characteristics between groups (fractional flow reserve: 0.85 ± 0.04 vs. 0.89 ± 0.06; diameter stenosis (DS): 43.4 ± 8 vs. 40.1 ± 10.7%; plaque burden 54.98 ± 5.8 vs. 49.76 ± 8.31%; and maxLCBI4 mm 402 [348; 564] vs. 373 [298; 516]; p=NS for all comparisons between groups 1 and 2, respectively). Seven BVSs were implanted 3 ± 1 days after STEMI in six patients, without complications. At angiographic follow-up (712 [657; 740] days), a significant and similar reduction of maxLCBI4 mm was observed in both groups, with a median change of 306 [257; 377] in group 1 vs. 300 [278; 346] in group 2 (p=0.44). DS was significantly lower in group 1 vs. group 2 (19.8 ± 7 vs. 41.7 ± 13%, p=0.003), while plaque burden remained unchanged in both groups. Overall survival was 100%, target lesion failure was 13%, and stent thrombosis was 0%. CONCLUSIONS: BVS + OMT and OMT appear as similarly safe and effective in reducing maxLCBI4mm in NC-LRPs at 2-year follow-up after STEMI.

Optimizing pharmacists' detection of prescribing errors: Comparison of on-ward and central pharmacy services.

WHAT IS KNOWN AND OBJECTIVE: Prescribing errors are the leading cause of adverse drug events in hospitalized patients. Pharmaceutical validation, defined as the review of drug orders by a pharmacist, associated with clinical decision support (CDS) systems, significantly reduces these errors and adverse drug events. In Belgium, because clinical pharmacy services have limited public financial support, most pharmaceutical validations are performed at the central pharmacy instead of on-ward, by hospital pharmacists doing dispensing activities. In that context, we aimed at evaluating whether the strategy of CDS-guided central validation was the most appropriate method to improve the quality and safety of medicines' use compared to an on-ward pharmaceutical validation. METHODS: Our retrospective observational study was conducted in a Belgian tertiary care hospital, in 2018-2019. Data were extracted from our validation software and pharmacists' charts. The outcomes of the study were the number of pharmaceutical interventions due to the detection of prescribing errors, reasons for interventions, their acceptance rate and their potential clinical impact (according to two blinded experts) in the central pharmacy and on-ward validation groups. RESULTS AND DISCUSSION: Despite the use of the same CDS, a pharmaceutical intervention following the detection of a prescribing error was made for 2.9% (20/698) of central group patients and 13.3% (93/701) of on-ward patients (χ2  = 49.97, p < 0.001). Interventions made at the central pharmacy (n = 20) mostly relied on CDS-alerts (i.e. drug-drug interaction [25%] or overdosing [20%]) while interventions made on-ward (n = 93) were also for pharmacotherapy optimization (i.e. no valid indication [25%] or inappropriate drug's choice [11%]). The on-ward validation group showed a higher acceptance rate compared to the central group (84% and 65%, respectively [Fisher's test, p = 0.053]). Proportions of interventions with significant or very significant clinical impact were similar between the two groups but as fewer interventions were made centrally, a significant proportion of errors were probably not detected by the central validation. WHAT IS NEW AND CONCLUSION: On-ward pharmaceutical validation leads to a higher rate of prescribing error detection. Pharmaceutical interventions made by on-ward pharmacists are also better accepted and more relevant, going further than CDS-alerts.

Endcapping of high-power 3 µm fiber lasers.

Fiber tip photodegradation through OH diffusion currently limits the long term operation of high-power fiber lasers and amplifiers operating near 3 µm. To address this issue, we investigate the resistance to OH diffusion of fluoride and oxide endcaps manufactured out of ZrF$_4$4, AlF$_3$3, GeO$_2$2, SiO$_2$2 and Al$_2$2O$_3$3 fibers. To this extent, the endcaps are spliced at the output of a 20 W continuous-wave fiber laser operating at 2.8 µm and their degradation over a 100 h time period is monitored. While the fluoride-based endcaps underwent failure during the first 10 h, their oxide counterparts survived the experiment, although showcasing degradation which was reflected as an increase of the endface temperature over time. To overcome this issue, we propose a novel method to completely suppress OH diffusion which consists in sputtering a nanoscopic diffusion barrier film made of silicon nitride (Si$_3$3N$_4$4) on the output face of the endcap. The effectiveness of the approach is validated on Al$_2$2O$_3$3, ZrF$_4$4 and AlF$_3$3 endcaps which show no sign of degradation after being used for more than a 100 h at the output of a 3 µm high-power fiber laser.

3.42 µm lasing in heavily-erbium-doped fluoride fibers.

In this paper, we investigate laser emission at 3.4µm in heavily-erbium-doped fluoride fibers using dual-wavelength pumping. To this extent, a monolithic 7 mol% erbium-doped fluoride fiber laser bounded by intracore fiber Bragg gratings at 3.42 µm is used to demonstrate a record efficiency of 38.6 % with respect to the 1976 nm pump. Through numerical modeling, we show that similar laser performances at 3.4 µm can be expected in fluoride fibers with erbium concentrations ranging between 1 - 7 mol%, although power scaling should rely on lightly-doped fibers to mitigate the heat load. Moreover, this work studies transverse mode-beating of the 1976 nm core pump and its role in the generation of a periodic luminescent grating and in the trapping of excitation in the metastable energy levels of the erbium system. Finally, we also report on the bistability of the 3.42 µm output power of the 7 mol% erbium-doped fluoride fiber laser.

20 W splice-free erbium-doped all-fiber laser operating at 1610 nm.

We report on a splice-free erbium-doped all-fiber laser emitting over 20 W at a wavelength of 1610 nm, with a slope efficiency of 19.6 % and an overall efficiency of 18.3% with respect to the launched pump power at 976 nm. The simple cavity design takes advantage of fiber Bragg gratings written directly in the gain fiber through the polymer coating and clad-pumping from a single commercial pump diode to largely simplify the assembling process, making this cavity ideal for large-scale commercial deployment. Two single-mode and singly erbium-doped silica fibers were fabricated in-house: the first to assess the effects of a high erbium concentration (0.36 mol.% Er2O3), yielding a low efficiency of 2.5 % with respect to launched pump power, and the second to achieve the improved result mentioned above (0.03 mol.% Er2O3). Numerical simulations show the link between the performance of each cavity and ion pair-induced quenching.

Gain-switched fiber laser at 3.55 µm.

We report, to the best of our knowledge, the first demonstration of a gain-switched fiber laser operating near 3.5 µm. A dual-wavelength pumping scheme consisting of a 1976 nm Q-switched fiber system and a continuous-wave 976 nm laser diode were used to gain-switch a monolithic erbium-doped fluorozirconate fiber laser cavity at 3.552 µm. Stable pulses were produced for repetition rates ranging between 15 and 20 kHz, and a record peak power of 204 W was achieved at 15 kHz. A quenching phenomenon was also observed at 15 kHz for 1976 nm pulse energies beyond 180 µJ.

5.6 W monolithic fiber laser at 3.55 µm.

We report, to the best of our knowledge, the first monolithic erbium-doped fluorozirconate fiber laser bounded by two fiber Bragg gratings (FBGs) operating at 3.55 µm. Its output power and total optical efficiency are 5.6 W and 26.4% respectively, the highest ever achieved at this wavelength from a fiber laser. The monolithic design of the cavity also increases its stability and prevents fiber tip damage which has limited prior demonstrations to a maximum output power of 1.5 W. This Letter also studies the performances of the laser cavity for various output FBG reflectivities and presents numerical modeling results exhibiting remarkable agreement with experimental results.

Impact of left ventricular outflow tract ellipticity on the grading of aortic stenosis in patients with normal ejection fraction.

BACKGROUND: The pathophysiology of paradoxical low-gradient (LG) severe aortic stenosis (SAS) remains controversial. As low transvalvular flow has been implicated, we sought to investigate the impact of left ventricular outflow tract (LVOT) ellipticity on the estimation of the LV stroke volume, the calculation of the aortic valve area (AVA) by use of the continuity equation and on AS severity grading. METHODS: We studied 190 consecutive patients (mean age: 72 ± 13 years; male: 57%) with SAS (indexed AVA < 0.6 cm2/m2) and preserved LV ejection fraction, including 120 patients with severe high gradient (HG) AS and 70 with severe paradoxical LG-AS. AS severity, LV volumes and LVOT ellipticity were assessed by 2D-Doppler echocardiography and cardiac magnetic resonance (CMR). RESULTS: The LVOT exhibited an elliptical shape on CMR images, with a shorter anterior-posterior than median-lateral diameter (2.2 ± 0.2 vs 2.8 ± 0.3 cm, p < 0.01). Accordingly, the LVOT area measured by planimetry was larger than by 2D-echocardiography, assuming a circular orifice (4.9 ± 0.9 cm2 vs 3.7 ± 0.8 cm2, p < 0.01). Inputting the elliptical LVOT area into the continuity equation resulted in a 29% increase in the indexed AVA (from 0.41 ± 0.09 cm2 to 0.54 ± 0.10 cm2). Accordingly, 30 (43%) patients with severe paradoxical LG-SAS were reclassified as having moderate AS. Similar results were obtained when considering 3D-echo for direct planimetry of the LVOT in a subset of 75 patients. CONCLUSIONS: Our results confirm that the LVOT is elliptical in shape and that taking this parameter into account in the calculation of the AVA results in reclassification of 43% of patients with severe paradoxical LG-AS into moderate AS.

Watt-level erbium-doped all-fiber laser at 3.44 µm.

We demonstrate a 3.44 µm all-fiber laser emitting a maximum of 1.5 W at room temperature, the highest continuous power ever generated from a mid-IR fiber oscillator clearly beyond 3 µm. The laser operates on the 4F(9/2)→4I(9/2) transition of erbium-doped fluoride glasses and relies on a dual pumping scheme at 974 and 1976 nm. By combining a dichroic mirror deposited on the input fiber tip and a fiber Bragg grating as an output coupler, a stable laser emission is produced with a FWHM bandwidth of less than 0.6 nm. The laser cavity has an efficiency of 19% with respect to the launched pump power at 1976 nm and no saturation is observed provided 974 nm co-pumping is sufficient. The joint effect of the two pumps is also investigated.

Evaluation of a new semiautomated external defibrillator technology: a live cases video recording study.

AIM: To determine the effect of a new automated external defibrillator (AED) system connected by General Packet Radio Service (GPRS) to an external call centre in assisting novices in a sudden cardiac arrest situation. METHOD: Prospective, interventional study. Layperson volunteers were first asked to complete a survey about their knowledge and ability to give cardiopulmonary resuscitation (CPR) and use an AED. A simulated cardiac arrest scenario using a CPR manikin was then presented to volunteers. A telephone and semi-AED were available in the same room. The AED was linked to a call centre, which provided real-time information to 'bystanders' and emergency services via GPRS/GPS technology. The scene was videotaped to avoid any interaction with examiners. A standardised check list was used to record correct actions. RESULTS: 85 volunteers completed questionnaires and were recorded. Mean age was 44±16, and 49% were male; 38 (45%) had prior CPR training or felt comfortable intervening in a sudden cardiac arrest victim; 40% felt they could deliver a shock using an AED. During the scenarios, 56 (66%) of the participants used the AED and 53 (62%) successfully delivered an electrical shock. Mean time to defibrillation was 2 min 29 s. Only 24 (28%) participants dialled the correct emergency response number (112); the live-assisted GPRS AED allowed alerted emergency services in 38 other cases. CPR was initiated in 63 (74%) cases, 26 (31%) times without prompting and 37 (44%) times after prompting by the AED. CONCLUSIONS: Although knowledge of the general population appears to be inadequate with regard to AED locations and recognition, live-assisted devices with GPS-location may improve emergency care.

OLD-TAVR score to predict 2-year mortality in patients aged 75 years and more undergoing transcatheter aortic valve replacement.

PURPOSE: Decision-making on transcatheter aortic valve replacement (TAVR) in patients aged 75 years and older is complex. It could be facilitated by the identification of predictors of long-term mortality. This study aimed to identify predictors of 2-year mortality to develop a 2-year mortality risk score. METHODS: Cohort study of consecutive patients aged ≥ 75 years who underwent TAVR after a comprehensive geriatric assessment (CGA) at our university hospital between 2012 and 2019. Predictors of 2-year mortality were determined using multivariable Cox regression. A point-based predictive model was developed based on risk factors and subsequently internally validated by fivefold cross-validation. RESULTS: The 345 patients (median age 87 years, 54% women) were fit/vulnerable (32%), mildly frail (37%), or moderately/severely frail (31%). The overall 2-year mortality rate was 26%, predicted by atrial fibrillation, hemoglobin ≤ 10 g/dL, age ≥ 87 years, BMI ≤ 24, eGFR ≤ 50 ml/min, and moderate/severe frailty. The risk score (range 0-12), named OLD-TAVR score, for 2-year mortality showed good discriminative power (AUC 0.70) and remained consistent after fivefold cross-validation (cvAUC 0.69). A risk score ≥ 8 (prevalence 20%) predicted a 45% (95%CI: 34-58%) two-year mortality, with high specificity (86%) and good positive predictive power (+ LR 2.43). CONCLUSION: A 2-year mortality risk score (OLD-TAVR score) for very old patients undergoing TAVR was developed based on six bio-clinical items. A score ≥ 8 identified patients in whom 2-year mortality was very high and thereby the TAVR futile. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: Study protocol B403, 26/09/2022, retrospectively registered.

Late outcomes of renal denervation are more favourable than early ones: facts or fancies?

Following second-generation randomized trials, there is evidence that renal denervation (RDN) decreases blood pressure (BP), although to a lesser extent than suggested in the initial controlled and observational studies. The recent publication of the 36-month follow-up of the Symplicity HTN-3 trial has raised expectations, suggesting increasing, late benefits of the procedure, despite initially negative results. These findings come after those obtained at 36 months in the sham-controlled trial SPYRAL HTN-ON MED and in the Global Symplicity Registry. However, they are susceptible to biases inherent in observational studies (after unblinding for sham-control) and non-random, substantial attrition of treatment groups at 36 months, and used interpolation of missing BPs. More importantly, in SPYRAL HTN-ON MED and Symplicity HTN-3, long-term BP changes in patients from the initial RDN group were compared with those in a heterogeneous control group, including both control patients who did not benefit from RDN and patients who eventually crossed over to RDN. In crossover patients, the last BP before RDN was imputed to subsequent follow-up. In Symplicity HTN-3, this particular approach led to the claim of increasing long-term benefits of RDN. However, comparison of BP changes in patients from the RDN group and control patients who did not undergo RDN, without imputation of BPs from crossover patients, does not support this view. The good news is that despite the suggestion of sympathetic nerve regrowth after RDN in some animal models, there is no strong signal in favour of a decreasing effect of RDN over time, up to 24 or even 36 months. Still, current data do not support a long-term increase in the effect of RDN and the durability of RDN-related BP reduction remains to be formally demonstrated.

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial.

BACKGROUND: Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking. OBJECTIVES: The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO. METHODS: DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications. RESULTS: Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups. CONCLUSIONS: With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.

Surgical Treatment of Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation.

BACKGROUND: The optimal treatment of patients developing infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is uncertain. OBJECTIVES: The goal of this study was to investigate the clinical characteristics and outcomes of patients with TAVI-IE treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB). METHODS: Crude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery vs medical therapy on 1-year all-cause mortality in patients with definite TAVI-IE. The study used data from the Infectious Endocarditis after TAVI International Registry. RESULTS: Among 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (HRunadj: 0.85; 95% CI: 0.58-1.25) and 1-year all-cause mortality (HRunadj: 0.88; 95% CI: 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB was also not associated with lower mortality rates for in-hospital mortality (HRadj: 0.92; 95% CI: 0.80-1.05) and 1-year all-cause mortality (HRadj: 0.95; 95% CI: 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock. CONCLUSIONS: In this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patients' characteristics, pathogen, and IE-related complications.

Mitral Valve Infective Endocarditis after Trans-Catheter Aortic Valve Implantation.

Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.