Discussion
IE affects between 1 and 10 cases per 100000 individuals each year [1]. The prevalence is about 5% in prosthetic valves with no significant difference between mechanical and bioprosthetic valves [2,3]. In-hospital mortality of patients admitted with left-sided IE is between 15% and 30% depending on baseline conditions of the patients, the causative organism, and the presence of complications [4].
Our patient had history if Covid-19 infection 6 months ago and also hospital admission in recent months. Antonio ramus et al. detected an incidence of hospital acquired IE higher than usual during the first two months of the COVID-19 pandemic. Elderly patients with damaged valves or previous cardiac surgery, prolonged contact with the hospital, the presence of previous heart disease or invasive devices often characterize these patients. Optimal catheter care, early treatment of any local infection and appropriate use of diagnostic techniques(TEE) in patients with suspected IE during the peak of COVID-19 [5]. Furthermore, Cosyns et al. observed a worse prognosis in patients diagnosed with IE during the pandemic (i.e., cerebral embolism rate was 18.5% in 2019 vs. 56% in 2020) and in-hospital IE mortality reached 61% during the pandemic versus 31% in 2019 [6].
Approximately, half of the patients affected by IE require cardiac surgery to treat the infection or the associated complications. However, about one-third of the patients with an indication for surgery due to residual valvular lesion are not eligible for surgery due to high surgical risk [1,4].
Transcatheter Aortic Valve Implantation(TAVI) is currently a well-established therapeutic option in patients with severe aortic stenosis considered at prohibitive risk for open heart AV replacement [7]. But when the AV is damaged after IE, TAVI may be a potential therapeutic option (1) and data from an international registry study confirmed the early safety and clinical efficacy of TAVI in the bioprosthetic valve group over the native valve group [8].
There are very few cases in the medical literature on the use of TAVI following IE and even fewer cases of TAVI-in valve procedures after IE. In 2013, Albu et al. described the first case of a healed IE in a severe aortic homograft stenosis successfully treated with a self-expandable TAVI [7]. In 2015, Nguyen et al. described the first case of valve-in-valve-in-valve procedure to treat a healed IE in a patient treated with TAVI inside a surgical bioprosthetic valve by a second time successful TAVI [9].
Recent studies show that current antibiotic regimes are effective, allowing an infected valve to become sterile in a high proportion of patients, and whereas the presence of aortic IE is an absolute contraindication for TAVI, its use in patients with residual/pre-existing aortic lesion following “healed” IE, without predicting factors of active local infection which are diabetes mellitus, Staphylococcus aureus, and concomitant compromised mitral valve when conventional surgical AV replacement is rejected or high risk, was feasible, safe, and with comparable in-hospital and 1-year follow-up outcomes to that of the standard TAVI recipients [1,4].