Selective Valve Removal for Melody Valve Endocarditis: Practice Variations in a Multicenter Experience

Abstract

Guidelines for management of Melody transcatheter pulmonary valve (TPV) infective endocarditis (IE) are lacking. We aimed to identify factors associated with surgical valve removal versus antimicrobial therapy in Melody TPV IE. Multicenter retrospective analysis of all patients receiving Melody TPV from 10/2010 to 3/2019 was performed to identify cases of IE. Surgical explants versus non-surgical cases were compared. Of the 663 Melody TPV implants, there were 66 cases of IE in 59 patients (59/663, 8.8%). 39/66 (59%) were treated with IV antimicrobials and 27/66(41%) underwent valve explantation. 26/59 patients (44%) were treated medically without explantation or recurrence with average follow-up time of 3.5 years (range:1–9). 32% of Streptococcus cases, 53% of MSSA, and all MRSA cases were explanted. 2 of the 4 deaths had MSSA. CART analysis demonstrated two important parameters associated with explantation: a peak echo gradient ≥ 47 mmHg at IE diagnosis(OR 10.6, p < 0.001) and a peak echo gradient increase of > 24 mmHg compared to baseline (OR 6.7, p = 0.01). Rates of explantation varied by institution (27 to 64%). In our multicenter experience, 44% of patients with Melody IE were successfully medically treated without valve explantation or recurrence. The degree of valve stenosis at time of IE diagnosis was strongly associated with explantation. Rates of explantation varied significantly among the institutions.

Current status of transcatheter intervention for complex right ventricular outflow tract abnormalities

“…However, there were no significant differences in the estimated survival free of endocarditis or survival free of valve replacement due to IE between the Melody TPVR group ( n = 241) and SPVR group ( n = 211) in a comparative study 141 . It is important to realize that IE after TPVR may be treatable with IV antimicrobial therapy, and explants of the valve may only be required if there is significant valve dysfunction 146 . Various risk factors of IE have been advocated, with another multicenter retrospective study of 845 post Melody TPVR patients revealing invasive RV-PA pressure gradients (per five mmHg) as an independent risk factor of IE (adjusted hazard ratio HR: 1.19, 95% CI 1.07-1.32; p =0.002) 89 .…”