Post TAVR candida endocarditis - A case study

Dr Thierry Carrel, at University Hospital, University of Bern, Bern, Switzerland and associates have reported a case of Candida Endocarditis after TAVR which has appeared in NEJM.

Transcatheter aortic valve replacement (TAVR) is currently an alternative to surgical aortic valve replacement (SAVR) in high surgical risk patients with severe aortic stenosis (AS). With the increasing number of cases of TAVR, reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited.

According to history, a 76-year-old man with a history of congestive heart failure and an ejection fraction of 45% presented to the emergency department with worsening shortness of breath. He had undergone transcatheter aortic-valve replacement (TAVR) 9 months earlier. His temperature was 39.0°C, and a grade 5 systolic murmur (associated with a palpable thrill) was detected on cardiac examination.

Courtesy NEJM

The chest radiograph of patient showed changes consistent with pulmonary oedema. Laboratory results were notable for a white-cell count of 16,000 cells per cubic millimetre (reference range, 4000 to 10,000) and a C-reactive protein level of 120 mg per litre (reference range, <5). Six consecutive blood cultures were positive for Candida parapsilosis. Treatment with antifungal agents was initiated. Prosthetic-valve endocarditis was confirmed on transesophageal echocardiography, which revealed large vegetation causing substantial obstruction of the prosthetic valve (transvalvular mean pressure gradient, 52 mm Hg; aortic-valve area, 0.5 cm²).

A Surgical aortic-valve replacement was performed, and the vegetation and the native leaflet were visualized. The postoperative course was complicated by wound infection at the surgical site. The patient was discharged but was readmitted 4 weeks later with pneumonia. He died from an aspiration event after a 2-month hospitalization.

For further reference log on to : DOI: 10.1056/NEJMicm1809948