Infective Endocarditis After Transcatheter Aortic Valve Implantation: Current Challenges in Diagnosis, Management, and Prevention.

The worldwide use of transcatheter aortic valve implantation (TAVI) is increasing because of an aging population and proven cost-effectiveness. As a result, the incidence of infective endocarditis related to TAVI is expected to increase. These infections have distinct epidemiological features because of the patients' advanced age and comorbidities, with enterococcal infections being more frequent currently, although this might change as indications for TAVI expand to include younger and low surgical risk patients. Diagnosing TAVI-associated endocarditis is challenging and requires a high degree of clinical suspicion. Imaging studies such as echocardiography, computed tomography, and positron emission tomography/ computed tomography are crucial not only to confirm the diagnosis of infective endocarditis but also to precisely assess the extent of infection, which is essential for guiding patient management and determining surgical decision-making. Surgical indications are not different than those of surgical aortic valve replacement but TAVI presents specific challenges related to the patients' profile and difficulties of surgical TAVI explantation. For patients unsuitable for surgery, individualized antibiotic treatment plans are necessary, including decisions on drug selection and duration including prolonged suppressive therapy. Although expert consensus suggests enterococcal coverage in prophylactic antibiotics during TAVI, there is no solid evidence to support this recommendation. Additionally, preventive measures beyond antibiotic prophylaxis should be implemented. Because of the anticipated increase in TAVI-related endocarditis cases, collaborative efforts to design and conduct randomized studies are needed to improve prevention and treatment strategies in this growing patient population.