Impact of active cancer disease on the outcome of patients undergoing transcatheter aortic valve replacement

Mangner, Norman; Woitek, Felix; Haußig, Stephan; Holzhey, David; Stachel, Georg; Schlotter, Florian; Höllriegel, Robert; Mohr, Friedrich W.; Schuler, Gerhard; Linke, Axel

doi:10.1111/joic.12458

Cited by 53 publications

(54 citation statements)

References 29 publications

(55 reference statements)

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“…After screening the abstract from these articles, only 25 studies were eligible for full-text screening. In total, three studies16–18 (all observational) with a total of 5162 patients (368 patients (7.1%) with AC) were included in the final analysis (figure 1). The summary of the included studies and their main results are shown in table 1, the baseline characteristics of their populations are shown in table 2 and the cancer type distribution is shown in table 3.…”

Section: Resultsmentioning

confidence: 99%

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Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

et al. 2020

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BackgroundPatients with severe aortic stenosis and concomitant active cancer (AC) are considered high-risk patients and usually are not allowed to undergo surgical valve replacement. Transcatheter aortic valve replacement (TAVR) may be an attractive option for them; however, little is known about the outcomes of TAVR in this subset of complex patients.Methods and resultsIn this meta-analysis, Medline, Cochrane Library and Scopus databases were searched (anytime up to April 2019) for studies evaluating the outcomes of TAVR in patients with or without AC. We assessed pooled estimates (with their 95% CIs) of the risk ratio (RR) for the all-cause mortality at the 30-day and 1-year follow-ups, a 4-point safety outcome (any bleeding, stroke, need for a pacemaker and acute kidney injury) and a 2-point efficacy outcome (device success and residual mean gradient (mean difference)). Three studies (5162 patients) were included. Of those patients, a total of 368 (7.1%) had AC. Apart from a significantly higher need for a postprocedural pacemaker (RR 1.29, 95% CI 1.06 to 1.58, p=0.01), TAVR in patients with AC resulted in similar outcomes for safety and efficacy at the 30-day follow-up compared with those without AC. Patients with AC experienced similar rates of the all-cause mortality at the 30-day follow-up compared with those without (RR 0.92, 95% CI 0.53 to 1.59, p=0.76); however, the all-cause mortality was significantly higher in patients with AC at the 1-year follow-up (RR 1.71, 95% CI 1.26 to 2.33, p=0.0006). This mortality difference was independent of cancer stage (advanced or limited) at the 30-day follow-up but not at the 1-year follow-up; only patients with limited cancer stages showed similar all-cause mortality rates compared with those without cancer at the 1-year follow-up (RR 1.22, 95% CI 0.79 to 1.91, p=0.37).ConclusionTAVR in patients with AC is associated with similar 30-day and potentially worse 1-year outcomes compared with those in patients without AC. The 1-year all-cause mortality appears to be dependent on the cancer stage. Involving a specialised oncologist who usually considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices might refine the risk assessment process among these patients.PROSPERO registration numberCRD42019120416.

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Section: Resultsmentioning

confidence: 99%

“…Considering that data on TAVR outcomes in patients with or without AC are very few and heterogeneous (with some investigators reporting similar all-cause mortality rates16 at the 1-year follow-up while others did not),17 18 we conducted this systematic review and meta-analysis to provide information for improving the clinical decisions.…”

Section: Introductionmentioning

confidence: 99%

Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

et al. 2020

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“…Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) ow chart of the study selection is shown in Figure 1. Major excluded articles [19,[34][35][36][37][38][39] with reasons are reported in the Supplemental Appendix. The 4 included studies enrolled a total of 2054 patients; 164 patients with prior C-XRT, and 1890 patients without prior C-XRT.…”

Section: Literature Search Resultsmentioning

confidence: 99%

Outcomes After Transcatheter Aortic Valve Replacement in Cancer Survivors with Prior Chest Radiation Therapy: A Systematic Review and Meta-Analysis

Zafar

Mustafa

Miller

et al. 2020

Preprint

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Background : Cancer survivors with prior chest radiation therapy (C-XRT) frequently present with aortic stenosis (AS) as the first manifestation of radiation-induced heart disease. They are considered high-risk for surgical valve replacement. Transcatheter aortic valve replacement (TAVR) is as an attractive option for this patient population but the outcomes are not well established in major clinical trials. The authors performed a systemic review and meta-analysis of clinical studies for the outcomes after TAVR in cancer survivors with prior C-XRT. Methods: Online databases were searched from inception to April 2020 for studies evaluating the outcomes of TAVR in patients with and without C-XRT. We analyzed the pooled estimates (with their 95% confidence intervals) of the odds ratio (OR) for the all-cause mortality at 30-day and 1-year follow-ups, 4-point safety outcomes (stroke, major bleed, access-related vascular complications and need for a pacemaker), a 2-point efficacy outcome (mean aortic valve gradient and left ventricular ejection fraction) and worsening of congestive heart failure (CHF). Four studies were included following 2054 patients with and without prior C-XRT exposure (164 patients and 1890 patients respectively). Results: The C-XRT group had similar 30-day mortality compared to the control group (OR 1.29, 95% CI 0.64 to 2.58, p=0.48). The 1-year mortality was higher in the C-XRT group (OR 1.97, CI 1.15 to 3.39, p=0.01). Apart from higher congestive heart failure (CHF) exacerbation in the C-XRT group (OR 2.03, CI 1.36 to 3.04, p=0.0006), TAVR resulted in similar safety and efficacy outcomes in both groups. Conclusion: TAVR in the C-XRT group has similar 30-day mortality, safety, and efficacy outcomes compared to the control group; however, they have higher 1-year mortality and CHF exacerbation. Including an oncologist to the cardiology team who considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices may refine the risk assessment for these patients. The quality of analyzed data is modest, warranting randomized trials to assess the true benefits of TAVR in these patients.

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“…The difference in outcomes for patients with cancer and active disease versus those in remission was demonstrated recently in a registry that included 1821 subjects treated by TAVR [24]. Ninety-nine patients (5.4%) had different types of active cancer, while 251 patients had a history of treated cancers, currently in remission.…”

Section: Tavr In Cancer Patientsmentioning

confidence: 98%

“…The prevalence of cancer in patients with severe AS varies between 5.4 and 26% [24,28]. There are very few reports regarding the prognosis of patients with valvular disease and cancer, and even less are available in patients with AS.…”

Section: Aortic Stenosis Prevalence and Prognosis In Cancer Patientsmentioning

confidence: 99%

The Onco-cardiologist Dilemma: to Implant, to Defer, or to Avoid Transcatheter Aortic Valve Replacement in Cancer Patients with Aortic Stenosis?

et al. 2019

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Purpose of Review Aging is associated with an increased prevalence of both cancer and heart disease. The progression of aortic valve calcification to aortic stenosis may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy with mediastinal involvement. Symptomatic aortic stenosis is occasionally diagnosed in cancer patients undergoing cardiovascular evaluation; likewise, cancer is often recognized during assessment preceding aortic valve interventions. In these complex cases, physicians face difficult treatment decisions. Due to a myriad of clinical presentations of cancer and valve disease, specific guidelines for this patient population are not currently in place. Management is currently based on clinical judgment, on an individual basis. Recent Findings Patients with cancer in remission or with a favorable prognosis should be treated according to current cardiovascular guidelines. In these patients, aortic valve replacement can be performed either by surgery or transcatheter. Significant challenges arise in patients with active cancer, especially those receiving anti-cancer treatment. Recent data suggests that these patients can be offered aortic valve replacement, with a trend of favoring the transcatheter route in order to minimize perioperative This article is part of the Topical Collection on Cardio-Oncology

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Impact of active cancer disease on the outcome of patients undergoing transcatheter aortic valve replacement

Abstract: The presence of ACD in patients undergoing TAVR is associated with significantly higher 1-year mortality.

Cited by 53 publications

References 29 publications

Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

Outcomes After Transcatheter Aortic Valve Replacement in Cancer Survivors with Prior Chest Radiation Therapy: A Systematic Review and Meta-Analysis

The Onco-cardiologist Dilemma: to Implant, to Defer, or to Avoid Transcatheter Aortic Valve Replacement in Cancer Patients with Aortic Stenosis?

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