TCT-609 Choosing Between Transcatheter, Surgical, and Medical Management in Cancer Patients With Severe Aortic Stenosis

Background: Elderly patients with severe aortic stenosis (AS) are increasingly diagnosed with cardiac amyloidosis (CA). It is unclear whether dual AS-CA has worse outcomes or may even result in futility of transcatheter aortic valve replacement (TAVR). Objective: To identify diagnostic predictors and outcomes of AS-CA compared to lone AS. Methods: Severe AS TAVR referrals at three international sites underwent clinical and laboratory assessment, six-minute walk test, ECG, transthoracic echocardiography with strain analysis, and blinded research 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1-3 increasingly positive) prior to intervention. Transthyretin CA (ATTR) was diagnosed by bone scintigraphy, unremarkable serum/urine free light chain assessment; light-chain CA (AL) was diagnosis by endomyocardial biopsy. All-cause mortality was captured from national registries. Results: 408 patients (age 83.4±6.5 years, 49.8% male) were recruited. DPD bone scintigraphy was positive in 11.6% (n=47, Grade-1 3.7%[15]) Grade-2/3 7.9%[32]). Positivity was associated with QRS duration (OR 2.5, 95%CI 1.1-5.5, p=0.02), voltage/mass-ratio (OR 0.4, 95%CI 0.2-0.9, p=0.02), history of carpal tunnel syndrome (OR 1.6, 95%CI 1.1-2.3, p=0.02). An additional two cases had biopsy proven AL-CA. Heart Team decision (blinded to bone scintigraphy) resulted in TAVR in 333 (81.6%), surgical aortic valve replacement in 10 (2.5%) and medical management in 65 (15.9%). After a median of 1.7 years, 22.9% of patients had died. AS-CA had a worse 1-year mortality than lone AS (24.5 vs 13.9%, p=0.045, Figure 1A), but there was no difference post valve intervention (p=0.7), which improved outcomes in both lone AS and AS-CA compared to medical management (Figure 1B+C). Discussion: Dual pathology of AS-CA is common in elderly AS patients. AS-CA is prognostically slightly worse than lone AS, but not if treated by valve intervention. Based on this data, TAVR should not be witheld in AS-CA.

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Cost effectiveness of transcatheter aortic valve replacement compared to medical management in inoperable patients with severe aortic stenosis: Canadian analysis based on the PARTNER Trial Cohort B findings

Journal of Medical Economics ◽

10.3111/13696998.2013.770747 ◽

2013 ◽

Vol 16 (4) ◽

pp. 566-574 ◽

Cited By ~ 16

Author(s):

Rebecca L. Hancock-Howard ◽

Christopher M. Feindel ◽

Josep Rodes-Cabau ◽

John G. Webb ◽

Ann K. Thompson ◽

...

Keyword(s):

Cost Effectiveness ◽

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Medical Management ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Transcatheter Aortic Valve

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An update on the management and outcomes of cancer patients with severe aortic stenosis

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.28052 ◽

2018 ◽

Vol 94 (3) ◽

pp. 438-445 ◽

Cited By ~ 10

Author(s):

Michael Schechter ◽

Dinu Valentin Balanescu ◽

Teodora Donisan ◽

Tariq J. Dayah ◽

Biswajit Kar ◽

...

Keyword(s):

Aortic Stenosis ◽

Cancer Patients ◽

Severe Aortic Stenosis

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Management and outcomes of severe aortic stenosis in cancer patients

American Heart Journal ◽

10.1016/j.ahj.2011.03.013 ◽

2011 ◽

Vol 161 (6) ◽

pp. 1125-1132 ◽

Cited By ~ 31

Author(s):

Syed Wamique Yusuf ◽

Ambreen Sarfaraz ◽

Jean-Bernard Durand ◽

Joseph Swafford ◽

Iyad N. Daher

Keyword(s):

Aortic Stenosis ◽

Cancer Patients ◽

Severe Aortic Stenosis

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Abstract 19770: TAVR Versus Medical Management Among Patients With Severe Aortic Stenosis and Left Ventricular Systolic Dysfunction

Circulation ◽

10.1161/circ.132.suppl_3.19770 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Amit N Vora ◽

John K Harrison ◽

Allison Dunning ◽

Phillip Schulte ◽

Matthew W Sherwood ◽

...

Keyword(s):

Aortic Stenosis ◽

Medical Management ◽

Left Ventricular Systolic Dysfunction ◽

Severe Aortic Stenosis ◽

Therapeutic Option ◽

Statistical Significance ◽

Systolic Dysfunction ◽

Left Ventricular ◽

Ventricular Systolic Dysfunction ◽

Historical Cohort

Background: The decision for transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS) and left ventricular systolic dysfunction (LSVD) can be challenging. We sought to evaluate mortality differences in patients with AS and LVSD undergoing TAVR compared with a medically matched historical cohort. Methods: We studied 206 patients who underwent TAVR and had an echocardiogram that demonstrated LVSD within six months prior to the procedure and a matched medically managed historical cohort (n = 206). All TAVR patients had severe aortic stenosis and high or extreme risk for open surgical AVR as determined by the Duke multidisciplinary team. Patients were matched 1:1 using optimal matching methods by AS resting mean gradient and/or peak velocity, age, gender, LVEF, and EURO score. LVSD was subclassified into mild (LVEF 36-50%) or severe (LVEF ≤35%). We used Cox multivariable modeling to assess the relationship between TAVR and all-cause mortality censored at 3 years. Results: The median age of the cohort was 82 (IQR 76-87). Compared with the medically matched cohort, TAVR patients were more likely to be male, have a history of ischemic heart disease, renal insufficiency, CHF, and prior CABG (all p<0.05). TAVR was associated with mortality reduction compared with medical management (HR 0.26, 95% CI 0.17-0.40, p<0.0001), which persisted after multivariable adjustment (HR 0.19, 95% CI 0.12-0.30, p<0.0001) (Figure). After adjustment, TAVR provided a larger decrease in mortality risk in patients with LVEF ≤ 35% (HR 0.25, 95%CI 0.06-1.01), than in patients with LVEF 36-50% (HR 0.42, 95%CI 0.14-1.27), but this difference did not reach statistical significance (p interaction = 0.52). Conclusion: Compared with medical management, TAVR is associated with higher survival with a trend for benefit in patients with severe LVSD. Given the poor prognosis associated with medical management, TAVR should be explored as a therapeutic option in patients with AS and LSVD.

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