Transcatheter aortic valve replacement infective endocarditis presenting as ascending aorta false aneurysm-a new clinical entity?

Objectives: Infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR) is rare. We describe patients referred to a tertiary heart center endocarditis team, with post-TAVR IE complicated by infected ascending aorta false aneurysms. Methods: Among 60 patients with post-TAVR IE who were referred to our center between January 2016 and October 2024, 7 (11.7%) patients were complicated by false aneurysm and aortitis. In all cases, self-expanding transcatheter heart valves (THVs), primarily Symetis ACURATE neo, were used. Results: Infected false aneurysm formation mainly at the tip of the THV stabilization arches and aortitis were identified only on cardiac computerized tomography. Five patients underwent surgical explant of the TAVR valve with aortic valve replacement. Interposition graft replacement of the ascending aorta was performed in 4 cases whereas 1 patient underwent aorta patch repair. Mitral valve surgery and coronary artery bypass graph were performed as a concomitant procedure in 2 cases. Two patients were managed conservatively due to extreme surgical risk. One patient died perioperatively, and one patient died during follow-up. Conclusions: Unlike prosthetic valve endocarditis after surgical aortic valve replacement, TAVR-IE may involve the ascending aorta, leading to life-threatening false aneurysm formation at the tip of the THV stabilization arches, where the device was adherent to the aortic wall. This pathology often eludes detection by echocardiography, underscoring the essential role of cardiac computed tomography in diagnosis and surgical planning. Clinicians should maintain a high index of suspicion for this rare but unique life-threatening complication and consider early use of advanced imaging.