Author + information
- Received June 27, 2014
- Revision received September 5, 2014
- Accepted September 10, 2014
- Published online February 1, 2015.
- Ignacio J. Amat-Santos, MD∗,†,
- Henrique B. Ribeiro, MD∗,
- Marina Urena, MD∗,
- Ricardo Allende, MD∗,
- Christine Houde, MD‡,
- Elisabeth Bédard, MD∗,
- Jean Perron, MD∗,
- Robert DeLarochellière, MD∗,
- Jean-Michel Paradis, MD∗,
- Eric Dumont, MD∗,
- Daniel Doyle, MD∗,
- Siamak Mohammadi, MD∗,
- Mélanie Côté, MSc∗,
- José Alberto San Roman, MD† and
- Josep Rodés-Cabau, MD∗∗ ()
- ∗Department of Cardiology, Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
- †Department of Cardiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- ‡Department of Pediatric Cardiology, Centre Mère-Enfant, Quebec City, Quebec, Canada
- ↵∗Reprint requests and correspondence:
Dr. Josep Rodés-Cabau, Quebec Heart & Lung Institute, Laval University, 2725 Chemin Ste-Foy, G1V 4G5 Quebec City, Quebec, Canada.
Objectives The aim of this review is to describe the incidence, features, predisposing factors, and outcomes of prosthetic valve endocarditis (PVE) after transcatheter valve replacement (TVR).
Background Very few data exist on PVE after TVR.
Methods Studies published between 2000 and 2013 regarding PVE in patients with transcatheter aortic valve replacement (TAVR) or transcatheter pulmonary valve replacement (TPVR) were identified through a systematic electronic search.
Results A total of 28 publications describing 60 patients (32 TAVRs, 28 TPVRs) were identified. Most TAVR patients (66% male, 80 ± 7 years of age) had a very high-risk profile (mean logistic EuroSCORE: 30.4 ± 14.0%). In TPVR patients (90% male, 19 ± 6 years of age), PVE was more frequent in the stenotic conduit/valve (61%). The median time between TVR and infective endocarditis was 5 months (interquartile range: 2 to 9 months). Typical microorganisms were mostly found with a higher incidence of enterococci after TAVR (34.4%), and Staphylococcus aureus after TPVR (29.4%). As many as 60% of the TAVR-PVE patients were managed medically despite related complications such as local extension, embolism, and heart failure in more than 50% of patients. The valve explantation rate was 57% and 23% in balloon- and self-expandable valves, respectively. In-hospital mortality for TAVR-PVE was 34.4%. Most TPVR-PVE patients (75%) were managed surgically, and in-hospital mortality was 7.1%.
Conclusions Most cases of PVE post-TVR involved male patients, with a very high-risk profile (TAVR) or underlying stenotic conduit/valve (TPVR). Typical, but different, microorganisms of PVE were involved in one-half of the TAVR and TPVR cases. Most TPVR-PVE patients were managed surgically as opposed to TAVR patients, and the mortality rate was high, especially in the TAVR cohort.
- infective endocarditis
- transcatheter aortic valve implantation
- transcatheter pulmonary valve implantation
The use of transcatheter valves for the treatment of valve dysfunction has experienced a very rapid expansion since the initial experiences in the first years of the past decade (Online Refs. 1–4). Although the high procedural success rate and beneficial effects associated with transcatheter valve replacement (TVR) are widely recognized, some of the well-known risks associated with standard surgical treatment for valve disease also exist in TVR (Online Ref. 5), although the complications probably have modified features that may both make their diagnosis and management difficult and change their clinical impact and prognosis. This is the case with prosthetic valve endocarditis (PVE), a rare (3 to 9 cases per 100,000 people) but complex and life-threatening disease.
Although a few TVR series have reported the incidence of early infective endocarditis IE) (Online Refs. 1–9) (Figures 1 and 2⇓), data on PVE in the field of transcatheter valves are limited to case reports or small series (1–28, Online Ref. 10), which precluded any appropriate evaluation of the clinical characteristics of patients with this syndrome as well as of its management and prognosis. The objective of this systematic review was therefore to provide further insight into the baseline characteristics, incidence, disease features, management, and clinical outcomes of patients with IE as a complication of TVR (transcatheter aortic valve replacement [TAVR] and transcatheter pulmonary valve replacement [TPVR]).
All relevant articles in English about TAVR/TPVR and PVE published between December 2000 and June 2013 were systematically searched in BioMedCentral, Google Scholar, and PubMed. The following query terms were used: transcatheter/percutaneous pulmonary/pulmonic valve replacement/implantation, transcatheter/percutaneous aortic valve replacement/implantation, transcatheter heart valve, infective endocarditis, prosthetic valve endocarditis, valve infection, congenital heart disease treatment and modified Duke’s criteria. Further studies were sought by means of a manual search of secondary sources, including references from primary articles (backward snowballing) and contacts with international experts. We also searched for these topics as case reports in major cardiology meetings between 2004 and 2012.
Citations were first screened at the title/abstract level by 2 independent reviewers (I.J.A.S., H.B.R.). Potential divergences were resolved after consensus to gather all pertinent case reports and case series concerning PVE in TAVR and TPVR. Only cases with definite endocarditis according to modified Duke criteria were included (Online Refs. 11,12). Some additional cases of “probable endocarditis” were also included due to high suspicion of actual PVE and limited sensitivity of the diagnostic criteria in their particular context. Early PVE was defined, according to the guidelines, as that occurring within the first 12 months after the valve replacement (Online Ref. 11).
Gathered data included baseline clinical, echocardiographic, and TVR procedural characteristics. Data on PVE clinical presentation, invasive procedures (any potential source of infection), etiology, in-hospital or 30-day complications, and mortality at any time point were also gathered. Main baseline characteristics of the TAVR-PVE patients were compared with those of patients included in previous TAVR registries (Online Refs. 13–20), the PARTNER (Placement of AoRTic TraNscathetER Valve) trial (Online Refs. 6,7), and largest surgical series including the main types of aortic bioprosthesis (Online Refs. 21–25). A similar comparison was also performed for TPVR-PVE patients, including the largest TPVR series (Online Refs. 26–30) and the largest surgical series that reported the incidence of PVE in congenital heart disease (Online Ref. 31), pulmonary valve replacement (Online Ref. 32), and Ross intervention (Online Ref. 33).
Categorical variables were reported as n (%), and continuous variables as mean ± SD or median (25th to 75th interquartile range) depending on variable distribution.
A total of 60 patients who underwent TVR, including 32 TAVR (1–16) and 28 TPVR (17–28), and who had PVE were included in the study. All cases were published between 2006 and 2013 (Online Table 1 for bibliographic sources and type of articles). The main baseline characteristics of TAVR and TPVR populations are summarized in Tables 1 and 2⇓, respectively. The mean age of TAVR patients was 80 ± 7 years, 66% of them were men, and the mean logistic EuroSCORE was 30.4 ± 14.0%. A comparison of these data with the data on the patients included large TAVR registries, the PARTNER trial (Online Refs. 6–9,19–22), and in surgical studies (Online Refs. 22–25) is shown in Figure 3.
TPVR patients were a much younger population (mean age, 19 ± 6 years), and only 10% of them were women. Tetralogy of Fallot was the most common underlying disease, and most patients (53%) had a homograft as a right ventricular–pulmonary artery conduit. The mean time between surgery and the TPVR procedure was 10 ± 3 years. Stenosis of the valve conduit was the most common reason for TPVR (60%). Baseline characteristics of the patients with PVE compared with those included in large TPVR series are shown in Figure 4.
Procedural and in-hospital course of TVR procedures
The main characteristics of TAVR and TPVR procedures are shown in Tables 1 and 2, respectively. Of the TAVR patients, 58% had received a balloon-expandable Edwards SAPIEN/SAPIEN XT valve (Edwards Lifesciences, Irvine, California) and 42% received a self-expandable CoreValve system (Medtronic, Minneapolis, Minnesota). The transcatheter valve was replaced via a transfemoral and transapical approach in 66% and 34% of patients, respectively. Post-procedural echocardiographic data were available for 21 patients, and the presence of mild or greater residual aortic regurgitation (AR) was observed in 16 of them (76%), with as many as 5 patients (24%) with moderate AR. This incidence of residual AR was higher than that observed in previous TAVR registries (mild or greater, 45.3%; moderate to severe, 11.8%) and in both cohorts of the PARTNER trial (mild or greater, 54%; moderate to severe, 12.3%) (Online Refs. 6–9,19–22). All patients who had TPVR had received a balloon-expandable Melody valve (Medtronic) implanted via the transfemoral venous approach; no data on hemodynamic results of the procedure were provided in any of the TPVR studies.
The location and environmental conditions where the interventions took place were reported in 2 TAVR studies only: a 4-case series that described a hybrid room as the usual place for TAVR procedures (Online Ref. 34) and the catheterization laboratory in a case report (Online Ref. 23). In the TPVR population, no information concerning the place where the interventions were performed was provided.
Data on antibiotic prophylaxis were not detailed in most cases. A wide variety of intravenous antibiotic regimens were administered including ampicillin, vancomycin ± ciprofloxacin, cefazolin ± gentamicin, or teicoplanin. No details were provided on whether single or multiple antibiotic doses were administered.
All procedures were considered successful in the TAVR and TPVR groups. In-hospital complications were reported exclusively in TAVR cases and included complete atrioventricular block leading to permanent pacemaker implantation in 2 cases, pneumonia/tuberculosis reactivation in 2 cases, and acute kidney injury requiring dialysis in 2 cases. The median length of stay after the TAVR procedure for those patients who did not present in-hospital PVE (all but 2 cases) was 6 days (interquartile range: 2 to 7 days).
Clinical features of PVE post-TVR
The main individual characteristics regarding the timing, clinical presentation, etiology, and location of PVE in the TAVR and TPVR groups are shown in Tables 3 and 4⇓⇓, respectively. The median time from the intervention to the diagnosis of PVE was 5.0 months (interquartile range: 3 to 9 months). The timeline of initial PVE symptoms is shown depicted in Figure 5.
The suspected sources of PVE were as follows: respiratory infections (TAVR, 4 cases; TPVR, 2 cases), dental interventions (TAVR, 3 cases; TPVR, 2 cases), skin infections (TAVR, 3 cases; TPVR, 2 cases), and urological (TAVR, 2 cases; TPVR, 0 cases) or gastrointestinal interventions (TAVR, 1 case). The 3 main sources (dental and respiratory/skin infections) were the same for both types of TVR, but a health care–related origin was more common in TAVR patients (42.1%) than in TPVR patients (18.2%) (p = 0.246). The source of infection remained undetermined in as many as 50% of the patients. Very little information was provided on the management of PVE prophylaxis after the TVR procedure, and failure to comply with recommendations was reported in 2 cases (18,22). A history of PVE existed in 2 pulmonary cases.
In 2 cases, only criteria for “possible” PVE were achieved, but given the high suspicion, they were finally included in the present review (7,8).
Fever (80%) and heart failure (22%) were the most common initial symptoms of PVE in the TVR population. Specific symptoms derived from septic emboli such as neurological symptoms (exclusively in the TAVR group) or pulmonary abscess in the TPVR group also occurred in 12.5% and 3.7% of the patients, respectively. Less frequent symptoms included cutaneous stigmata, local chills, loss of appetite, macrophage activation syndrome, and limb ischemia due to septic emboli. One patient remained asymptomatic, and PVE was suspected by new valve regurgitation and later confirmed by microbiological findings (Online Ref. 35).
The location of PVE as determined by transesophageal echocardiography is schematically depicted in Figure 6. The presence of vegetation was detected in 58.3% of the patients (50.0% and 68.4% in the TAVR and TPVR groups, respectively). In the TAVR group, the vegetation was located on the transcatheter valve leaflets in 7 patients (21.9%), on the valve stent frame in 2 patients (6.2%), and affected both structures in 3 patients (9.2%). Also, tricuspid and mitral valves presented vegetation in 1 (3.1%) and 3 patients (9.4%), respectively. The infection was restricted to the prosthetic valve in all TPVR cases (Table 5). No valve involvement could be confirmed in 4 patients (3 patients in the TAVR group and 1 in the TPVR group), with initial criteria for definite PVE and good response to antibiotic therapy.
The main microbiological findings differed in the TAVR and TPVR groups (Table 5). Although Enterococcus was the most frequent microorganism responsible for PVE in TAVR patients (34.4%), Staphylococcus aureus was predominant among TPVR patients (29.4%). Globally, positive cultures for “typical” microorganisms (Online Refs. 11,12) were obtained in about one-half of the patients with previous TVR (53.1% of TAVR patients and 47.1% of TPVR patients). Less common causal agents included Gram-negative bacilli in 3 cases, Corynebacterium (2 cases), fungal infections (Candida albicans and Aspergillus fumigatus), Histoplasma capsulatum, Bartonella henselae, and Granulicatella adjacens (1 case each). In 2 patients, all cultures including those performed after valve explantation, remained negative, but previous antibiotic therapy had been administered in both cases before blood samples were obtained.
Management and outcomes of TVR-related PVE
All patients received antibiotic therapy according to the etiology of PVE. Cardiac surgery and valve explantation were performed in 13 patients (41%) in the TAVR group and in 21 patients (75%) in the TPVR group. In the TAVR group, the rate of PVE-related surgery was twice as high in patients who had received a balloon-expandable valve (57%) compared with those who had a self-expandable valve (23%), despite a similar baseline risk profile in both groups as evaluated by the logistic EuroSCORE (30.5 ± 15.6% vs. 27.8 ± 13.5% in balloon- and self-expandable groups, respectively).
The most important surgical findings included incomplete valve endothelialization several months after TAVR in 1 case and sinotubular junction penetration by the struts in another case (Online Refs. 14,34).
The in-hospital mortality rate was 34.4% in the TAVR group, 30.8% in those patients who had surgery and valve explantation and 36.8% in those managed medically. In the TPVR group, the in-hospital mortality rate associated with the episode of PVE was 7.1%, 9.5% in patients who required surgery and none in those managed medically. Follow-up data were available in 15 patients in the TAVR group (47% of study population, 71% of the patients alive at hospital discharge), with a mean length of follow-up of 11 ± 9 months. Two additional cases of PVE-related death were reported in this period, at 1 and 3 months after hospital discharge. No follow-up information was available for patients treated with TPVR, which precludes long-term prognostic conclusions.
The rates of surgical management and mortality in TAVR and TPVR groups are summarized in Table 5.
PVE post-TVR: incidence and predisposing factors
Although the incidence of early PVE post-TVR has been more than 2% in some small series, larger studies have usually reported an incidence ≤1%, similar to that of surgical valve series (Online Refs. 21–25). In the PARTNER trial, the incidence of early PVE was 0.72%, which was comparable to the 1% rate observed in the surgical cohort (Online Ref. 6). However, one may wonder whether a lower rate of early PVE should be expected among TAVR patients, considering the less invasive nature of the procedure.
Some concerns have been raised about the adequacy of the sterile conditions in which the transcatheter valves are prepared and finally implanted. Although no details were provided about the location of TVR procedures in the reported cases of PVE, it is well known that most procedures are performed in the catheterization laboratory (Online Ref. 34), usually not achieving the same level of sterile conditions as an operating or hybrid room. Although the rate of bacterial infection in coronary cases is low (0.64%), positive blood cultures were obtained in 18% of the patients after the procedure (Online Ref. 35). Also, infective complications in the postoperative period affect as many as 15% of the patients (Online Ref. 36) and are a potential source of infection for PVE. Finally, the compression of the leaflets during transcatheter valve preparation and loading can be associated with some leaflet damage (Online Ref. 37), which indeed can favor the occurrence of PVE.
The present study showed that the vast majority of patients with PVE post-TVR were men, with as many as 66% and 90% of the patients in the TAVR and TPVR groups, respectively. This is in accordance with previous PVE studies (Online Ref. 5), in which about two-thirds of the patients with endocarditis were men. The protective asset of the female sex could be partially explained by the hypothetical endothelial protection by estrogen (Online Ref. 38).
The present study suggests that patients with endocarditis after TAVR are among those with the highest risk profile, with a mean logistic EuroSCORE close to 30% and frequent comorbidities such as diabetes, immunosuppression (i.e., steroids, myelodysplastic syndromes), and renal failure that have been recognized as predisposing factors for PVE (Online Ref. 5).
Finally, the presence of residual AR is well recognized as one of the most important limitations of TAVR. In the present study, most patients (75%) with echocardiographic data available had mild or greater residual AR, a much higher rate compared with previous TAVR series (Online Refs. 6–9,19–22). The presence of residual AR as a source of endothelial damage that may act as anchoring for the germs during episodes of transient bacteremia and its role as a predisposing factor for PVE needs to be further evaluated.
In TPVR patients, underlying congenital heart disease or the type of conduit used to repair the right-side anomalies were not related to a higher rate of PVE, albeit the presence of homografts in patients with PVE was ∼20% less frequent than in previous TPVR studies (Figure 2). On the other hand, stenotic malfunction of the percutaneous pulmonary valves (isolated or combined with regurgitation) seemed to be associated with a higher risk of PVE. Stenotic conduits may be more deteriorated and calcified and with higher shear stress forces that may predispose to PVE. However, previous studies have not clearly demonstrated a higher incidence of PVE in stenotic or regurgitant prosthetic or native valves (Online Refs. 26–30).
Antibiotic prophylaxis before TVR and before dental and other invasive procedures after TVR is currently decided on a case-by-case basis or according to institutional protocols, with the inherent limitations and variability of such an individualized strategy. This may also play a role in the occurrence of early PVE post-TVR. Of note, gastrointestinal procedures such as colonoscopies no longer require antibiotic prophylaxis as of 2009 European Society of Cardiology guidelines (Online Ref. 11). Even if publication bias may overestimate this problem, several patients included in this review presented with PVE after such procedures; it is therefore necessary to determine whether a step back in the recommendations may be necessary in TVR patients.
PVE post-TVR: etiology and diagnostic features
Staphylococci, fungi, and gram-negative bacilli have been found to be the main causes of early prosthetic valve endocarditis (Online Ref. 11). These “contaminant” germs were also a frequent etiology of early PVE after TAVR (36.7%), with enterococci as the predominant causative agents of early PVE in this group (Table 5). Previous studies predicted the increasing role of this pathogen as life expectancy increases and more aggressive therapies are administered to aged patients (Online Refs. 5,35). Enterococci are highly tolerant to antibiotic-induced killing, and eradication requires prolonged administration (as long as 6 weeks) of synergistic bactericidal combinations. Moreover, these microorganisms can be resistant to multiple drugs, including aminoglycosides, beta-lactams, and vancomycin (Online Ref. 35). This high rate of failure of antibiotics has major implications, as isolated medical management remains the most frequent strategy for the treatment of PVE after TAVR.
With regard to echocardiographic findings, valve prosthesis vegetation was present in about one-half of the patients diagnosed with PVE post-TVR. In TAVR patients, complications such as abscesses (47%), fistulae (9%), or the involvement of other valves (22%) were relatively common and much more frequent than that observed in previous series including native and surgical prosthetic valves (Online Refs. 21–25). On the other hand, in TPVR patients, the infection was limited to the valve prosthesis (either the leaflets, stent frame, or both) in all cases.
The microbiological, structural, and clinical particularities of patients treated with TVR may reduce the sensitivity of the Duke criteria (Online Refs. 11,12). Hence, some specific recommendations in this field may improve accuracy in the diagnosis of PVE (Online Ref. 39).
PVE post-TVR: management and outcomes
The rate of valve explantation in endocarditis studies has been as high as 75% for native valves and 50% for surgical bioprostheses (Online Ref. 40). In contrast, the rate of valve explantation in cases of PVE post-TAVR was 41%. Interestingly, this rate was much higher in balloon-expandable cases (57%) than in self-expandable ones (23%). Although many factors may have played a role in the differences between valve types, the much longer stent frame extending toward the ascending aorta of the CoreValve (Medtronic) system may increase technical difficulties during surgical valve explantation and may have been responsible for a lower rate of valve explantation in these cases. The high-risk profile of the patients undergoing TAVR may explain patients’ refusal of valve explantation in some of these cases even if more than one-third of them had a local extension of the infection and a significant number (30%) had complications such as heart failure and embolism that are frequent reasons to decide on surgery (Online Refs. 11,12). Indeed, about two-thirds of the patients with heart failure at admission were not operated on despite the proven survival benefits of surgery in that scenario (Online Refs. 11,41).
The rate of valve explantation observed in PVE post-TPVR was as high as 75%. Apart from the fact that the TPVR population is much younger than the usual IE patients, the right-side location (Online Refs. 41,42) and etiology of the endocarditis in such cases (S aureus as the most frequent agent) may explain the high valve explantation rate (Online Refs. 41,43).
Interestingly, the surgical explantation of many of these infected transcatheter valves and previous autopsy series (Online Refs. 43–45) have contributed to a better understanding of the predisposing anatomic factors, including extensive inflammatory reactions (Online Ref. 45), infection of the skirt and leaflets with extension and perforation of adjacent structures (Online Ref. 44), and (more controversial) the lack of valve endothelialization or thrombotic complications (Online Refs. 46–49). Also, Loeser et al. (Online Ref. 43) reported that signs suggestive of PVE after TAVR may be more frequent than commonly thought.
PVE has been associated with a high mortality rate (20% to 40%), with no major improvements in the survival rate of this life-threatening disease in the past 30 years (Online Ref. 11). The mortality rate observed in TAVR patients who had PVE (34%) was in accordance with such data, even though we cannot exclude a potential underestimation of the real mortality rate due to a publication bias (authors may tend to publish the cases that end well). The 7% mortality rate in TPVR patients that may seem low appears to be too high if we take into consideration the young population involved. Overall, this highlights the importance of maximizing the measures of asepsis and appropriate antibiotic prophylaxis and prompts us to think about the most appropriate strategy for the treatment of PVE post-TVR. The possibility of earlier and more frequent valve explantation in such cases to improve prognosis (Online Ref. 50) may be considered. Although major differences in the clinical profile between the TAVR and TPVR groups probably explain the differences in mortality rate, the higher rate of surgical treatment among TPVR patients may have contributed to the better outcomes compared with TAVR candidates. Further studies are needed to evaluate whether surgery improves outcomes despite the complex intervention and the risk of recurrent infection estimated at 15% after PVE (Online Refs. 40,51).
The present study has the limitations inherent to a systematic review that collects only the information described in the publications. Therefore, there might be relevant information omitted in the publications that could shed some light on this limitation. This also includes incomplete echocardiographic data, particularly regarding the characteristics (size, mobility) of the vegetation. In addition, all of the published papers found were either case reports or very small series, precluding comparison with the entire TVR population at risk. Additionally, the patients reported might have tended to have a better outcome than those who were not reported (selection bias).
PVE is an uncommon but life-threatening complication after TVR. Although the conditions of asepsis are frequently less strict than in surgical interventions, the incidence of early PVE post-TVR remains low (usually ≤1%) and similar to that of surgical series. In the TAVR population, this complication seems to be more frequent in male patients and in those with higher risk profile. In TPVR patients, PVE seems to occur more frequently in male patients with a stenotic (vs. regurgitation) conduit/valve as the main underlying disease. Although early PVE is considered to be acquired during the periprocedural time, the low rate of classic contaminant agents in favor of others such as enterococci, especially among TAVR patients, may suggest alternative source of infection. This is of major clinical importance because alternative antibiotic prophylaxis protocols may reduce the incidence of the disease. About two-thirds of the TAVR-PVE patients were managed medically, despite the fact that more than one-half of the patients had complications such as local extension, embolism, and heart failure. The mortality rate of PVE in these patients was high (more than 30%) and similar to that described in previous PVE studies. Most TPVR-PVE patients were managed surgically and underwent surgical explantation of the infected conduit valve. However, the mortality rate remained at 7% despite the very young age of this population.
The syndromic characteristics of PVE vary according to the underlying disease and the microorganism involved. PVE in transcatheter valve carriers represents a paradigm shift in PVE profile, involving very old (and high risk) or very young patients, both with a high rate of health-care procedures. This systematic review represents a first step toward a better understanding of the profile conditions and predisposing factors, etiology, management, and prognosis of PVE in patients with transcatheter valves. Future studies will have to determine the potential usefulness of improving asepsis/antibiotic prophylaxis in this challenging group of patients and finding a better strategy for an earlier diagnosis and better management to decrease the incidence of PVE and increase the survival associated with this life-threatening complication.
Dr. Amat-Santos received support from the Instituto de Salud Carlos III, Madrid, and the Hospital Clínico Universitario de Valladolid, Spain (Rio Hortega Contract). Dr. Rodés-Cabau is consultant for Edwards Lifesciences and St. Jude Medical. Dr. Dumont is consultant for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- aortic regurgitation
- infective endocarditis
- prosthetic valve endocarditis
- transcatheter aortic valve replacement
- transcatheter valve replacement
- transcatheter pulmonary valve replacement
- Received June 27, 2014.
- Revision received September 5, 2014.
- Accepted September 10, 2014.
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