Transcatheter Aortic Valve Replacement-Associated Prosthetic Valve Endocarditis Due to Pseudomonas aeruginosa Report of a Case and Review of the Literature

Introduction: In patients unsuitable for surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) is an alternative treatment modality for severe aortic stenosis. Prosthetic valve endocarditis (PVE) is uncommon after TAVR, and TAVR-PVE due to Pseudomonas aeruginosa is rare. We report a patient with P. aeruginosa TAVR-PVE and review the literature on the topic. Case: A 70-year-old woman with history of atrial fibrillation and severe aortic stenosis status post TAVR 4 months previously presented with a third episode of P. aeruginosa bacteremia. She initially developed P. aeruginosa bacteremia 18 days after TAVR. She failed two 6-week courses of intravenous cefepime treatment and then developed P. aeruginosa breakthrough bacteremia while on her third course of intravenous cefepime. Surgical intervention was declined by the patient. Two prior transesophageal echocardiograms (TEEs) were negative for vegetation, but after her breakthrough bacteremia, a repeat TEE showed a 1.5 x 0.8-cm vegetation on the aortic valve. Patient and family declined further therapy and transitioned to hospice and died 5 days later. Discussion: This is the sixth reported case of P. aeruginosa TAVR-PVE. Enterococcus faecalis, coagulase-negative Staphylococcus and Staphylococcus aureus, and streptococci are the most common etiologic agents causing TAVR-PVE. Diagnosis is difficult, and TEE may be nondiagnostic. Of the 6 reported cases, the only 2 to survive underwent SAVR despite high Society of Thoracic Surgery risk calculator scores. Conclusion: TAVR-PVE due to P. aeruginosa is rare and will likely not be cured by medical therapy alone. Surgical intervention with SAVR should be considered as the only available curative therapy despite high Society of Thoracic Surgery surgical risk scores.