Dental screening prior to valve interventions: Should we prepare transcatheter aortic valve replacement candidates for “surgery”?
Introduction
Infective endocarditis (IE) following surgical valve replacement has been reported to occurs in 1% to 6% of patients and is associated with high morbidity and mortality [1,2]. trans-Catheter aortic valve replacement (TAVR) has emerged as a therapeutic option for patients with symptomatic severe aortic stenosis considered at intermediate, high or prohibitive surgical risk [2]. Data on IE after TAVR have been limited to case reports and relatively small series with limited follow-up. The rate of IE within the year following TAVR has been reported to be 3.5%, ranging from 0.5% to 5% [[3], [4], [5]] similar to IE rates after surgical valve replacement. A recent change in the recommendations for prophylactic antibiotics added TAVR as an indication for post implantation IE prophylaxis [3]. However, the outcome of post TAVR IE has been grim demonstrating in-hospital complication and mortality rates as high as 87% and 47%, respectively.
Bacteremia has been shown to frequently occurs after dental procedures [6], with cumulative incidence of approximately 60%. Post dental procedure bacteremia may last up to 60 min after the procedure [[7], [8], [9]]. While the cause and effect between dental infection and IE has never been scientifically demonstrated, an association has been shown is very likely to exist. Accordingly current AHA/ACC guidelines recommend only surgical valve replacement candidates to have a dental screening prior to their operation for IE prevention [1,2]. The European society of cardiology recommends that potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material without specifying the route by which they may have been implanted [3]. This statement was based on the French society of oral surgery recommendations from 2006 regarding SVR only [10]. In a systematic review of literature regarding Pre-procedural dental screening for cardiovascular invasive procedures no satisfactory answers regarding dental care before cardiovascular invasive procedures could be provided [11]. At this time no specific recommendations exist regarding dental screening for TAVR candidates.
We aimed to compare oral dental screening findings in TAVR vs. surgical valve replacement (SVR) candidates and based on these findings to further assess the need for routine dental screening and treatment prior to TAVR similarly to patients undergoing SVR.
Section snippets
Study population
In October 2016 we extended our institutional surgical valve replacement pre-procedural preparation protocol to include TAVR candidates. A significant part of the protocol included oral-dental examination/treatment prior to surgery. Thus, between October 2016 and October 2017 all candidates for valve replacement (150 patients, age 70 ± 11, 50% male gender) were prospectively referred to our Oral medicine unit for evaluation and treatment if needed. The oral medicine team was blinded to the type
Patients' clinical characteristics
During the observation period 150 patients (58 TAVR and 92 SVR) were evaluated pre-operatively for valve replacement, referred for routine dental screening/treatment as appropriate.
Candidates for TAVR were octogenarians and nearly two decades older than surgical valve replacement candidates (Table 1). Representing their higher surgical risk profile most were hypertensive (twice the prevalence compared to SVR), they had worse renal function, twice the rate of previous percutaneous coronary
Discussion
TAVR and SVR share a common feature by the fact that they both introduce foreign prosthetic material into the endocardial surface. As such they may create a nidus for infective endocarditis. In the largely revised infective endocarditis prevention guidelines of 2007 [1] {Wilson, 2007 #14} a careful preoperative dental evaluation was recommended so that required dental treatment may be completed whenever possible before cardiac valve surgical repair or replacement or repair of congenital heart
Limitations
Our study represent our experience in one single tertiary cardio-vascular center with relative low number of patients, rather short period of follow-up, and the low expected event rate the study was not powered to identify longitudinal advantages other than the safety of the oral-dental screening approach. Larger cohorts with longer follow-up should probably further be assessed.
Conclusions
Oral health and need for pre-procedural dental treatment were not different among candidates for SVR and TAVR. Thus in TAVR patients initially denied surgery due to higher operative risk IE preventive oral-dental care seems to be justified.
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest
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