Echocardiographic predictors of mortality in infective endocarditis after transcatheter aortic valve implantation

Introduction The use of transcatheter aortic valve implantation (TAVI) is already the dominant treatment for severe aortic stenosis and is expected to increase following recent international guideline updates. By lowering the age threshold for TAVI, patients who previously would have undergone surgical replacement will instead live longer with a TAVI valve, thereby increasing their cumulative lifetime risk of TAVI-associated infective endocarditis (TAVI-IE), a serious complication. Echocardiography is essential for the diagnosis and follow-up of TAVI-IE. Purpose To assess associations between echocardiographic measurements of left ventricular (LV) systolic function, LV geometry, and mortality in patients with TAVI-IE. Methods We included 71 consecutive patients with TAVI-IE who had undergone TAVI at the same tertiary centre between 2012 and 2023. Transthoracic echocardiography was performed at baseline before TAVI, at routine postoperative follow-up, and shortly after admission for TAVI-IE. The primary outcome was all-cause mortality. Cox-regression models were used to evaluate predictors of mortality. Results Mean LV ejection fraction (LVEF) was 56±11% at baseline, 57±9% at first postoperative follow-up, and 53±12% at admission for TAVI-IE (p=0.008 for baseline versus TAVI-IE). From baseline to admission for TAVI-IE, LV stroke volume declined from 79±23 mL to 66±25 mL (p=0.005). LV end-diastolic diameter did not change from baseline to TAVI-IE. There were 42 (59%) deaths during a mean follow-up of 2.7±2.3 years of follow-up after admission for TAVI-IE. Reduced LVEF (<50%) at baseline (HR 2.42, p=0.011), postoperative follow-up (HR 2.36, p=0.019), and at TAVI-IE diagnosis (HR 2.36, p=0.008) was associated with higher mortality. At admission for TAVI-IE, low LV stroke volume (<60 mL, HR 3.04, p=0.006) and low indexed LV stroke volume (<25 mL/m2, HR 2.30, p=0.043) were also associated with increased mortality. Development of clinical heart failure during admission further increased mortality risk (HR 3.95, p<0.001). LV mass, LV dilatation, paravalvular leakage and valvular vegetations were not associated with mortality. Conclusion In patients with TAVI-IE, reduced LVEF and LV stroke volume during hospitalization for TAVI-IE are strongly associated with mortality, underscoring the prognostic importance of routine assessment of LV systolic function in this high-risk population.