Dental screening prior to transcatheter versus surgical aortic valve replacement: International Survey of Current Practices

To the Editor, Transcatheter aortic valve replacement (TAVR) has been widely adopted as an alternative to surgical aortic valve replacement (SAVR) and has now overtaken SAVR as the most common treatment for severe aortic stenosis. Furthermore, indications are expanding with increased use in younger low‐risk patients. TAVR‐related infective endocarditis (TAVR‐IE) is an uncommon complication, being estimated at 0.87%/year and is associated with high mortality rates of 45.6% at 1 year. Dental seeding of oral microorganisms is an important source of TAVR‐IE and has been determined the probable cause in 23.5% of cases in one cohort. Dental findings and requirements for dental intervention are similar amongTAVR and SAVR patients. Despite this, current valvular guidelines recommend preoperative dental screening for SAVR without having specific recommendations for TAVR. We sought to establish current practices of TAVR and SAVR operators in regard to dental screening before valve intervention. We created an online survey (Survey MonkeyTM) which was distributed via email and social media targeting those performing TAVR and/or SAVR. Respondents were advised to answer the survey questions based on their current personal practices. Eighty responses were received from operators across 65 sites in 17 countries; most commonly Canada (30%), Republic of Ireland (15%), United States (11%), Italy (9%), and Israel (9%). The majority of respondents were Cardiologists/Interventional Cardiologists (78%) followed by Cardiac surgeons (18%), fellows (3%) and clinical nurse specialists (1%). The majority of respondents (74%) worked in high‐volume centers and estimated that their institution performed >100 TAVRs or SAVRs per annum. Preprocedural dental screening is most frequently performed by the patient's personal dentist for elective valve replacements (86%) and by in‐hospital dental or maxillofacial teams for urgent inpatient valve replacement (66%). Dental screening before elective outpatient TAVR versus SAVR is considered: “Mandatory” in 26% versus 48%, “Advised” in 22% versus 37%, and “Not Required” in 52% versus 15%, respectively (χ statistic = 21.4; p < 0.0001). Dental screening before urgent inpatient TAVR versus SAVR (excluding emergencies) is considered: “Mandatory” in 14% versus 19%, “Advised” in 19% versus 38%, and “Not Required” in 67% versus 43%, respectively (χ statistic = 8.1, p = 0.01). When comparing practice between regions, we found that for patients undergoing elective outpatient TAVR, dental screening was deemed “not required” in North America, Europe, and the Middle East in 38% versus 61% versus 75%, respectively (p = 0.065). However, in patients undergoing elective outpatient SAVR dental screening was deemed “not required” in North America, Europe, and the Middle East in 18% versus 9% versus 29%, respectively (p = 0.36). The key findings are summarized in Figure 1. This study highlights that mandatory preprocedural dental screening is not standard practice for many TAVR operators with >50% of operators in this survey deeming dental screening not required. Moreover, this practice appears prevalent across many countries, which gives cause for concern. There are limitations in that this is a relatively small sample with a predominant response from cardiologists over surgeons, despite this, however, significant differences in practice were still demonstrated. We argue that preprocedural dental screening for TAVR should be treated with the same degree of due diligence as SAVR has been for many years. Dental seeding of bacteria to a TAVR valve is a potentially preventable life‐threatening complication, and as a result warrants preprocedural dental screening, dental extraction (when appropriate) and requires formal documentation of dental clearance by a dentist before proceeding with TAVR, except in emergency situations. Additionally, future guidelines should consider specific dental screening recommendations to standardize work‐up for all transcatheter valvular interventions.