Coronary Atherosclerosis and Aortic Valve Disease as Long-Term Sequelae of Radiation Therapy in Childhood

Coronary atherosclerosis and valvular heart disease are rare, but potentially severe sequelae following mediastinal radiation therapy. We present a case of premature ischemic heart disease and severe aortic stenosis in a 40-year-old woman following radiation therapy in childhood. We stress the awareness of prior mediastinal radiation therapy as an important risk factor for premature coronary atherosclerosis and valvular heart disease, particularly in younger patients without classical risk factors for coronary artery disease.

Combined Coronary Artery Bypass Grafting and Transcatheter Aortic Valve Replacement in a Patient with Severe Post-Radiation Damage

Chest radiotherapy is a common treatment for mediastinal malignancy. The long-term effect of radiation can harm several of cardiovascular structures including pericardium, myocardium, valvular system, conduction system, and coronary arteries. Cardiovascular disease is the most common non-malignancy cause of death in radiation-treated patient, most often occurs many years after treatment. Valvular heart disease secondary to mediastinal radiation mainly affect the aortic and mitral valves. We present a unique case of 58 years old women with history of past mediastinal radiotherapy who presented with few episodes of true syncope, complete AV block, severe aortic stenosis and significant ostial left main and ostial right coronary artery disease.

Short-Term Outcomes of Transcatheter Versus Isolated Surgical Aortic Valve Replacement for Mediastinal Radiation-Associated Severe Aortic Stenosis

Background: Surgical aortic valve replacement (SAVR) is associated with adverse outcomes in patients with radiation-associated aortic stenosis. Transcatheter aortic valve replacement (TAVR) may improve outcomes in this population. Methods: We evaluated 1668 TAVR and 2611 patients with SAVR enrolled in the Society of Thoracic Surgeons’ database between 2011 and 2018. Multiple logistic regression was used to compare 30- day outcomes between TAVR and SAVR. Propensity-matched analysis was performed to confirm results of the overall cohort. Additionally, the cohort was stratified into early (2011–2014) versus contemporary (2015–2018) TAVR eras, and 30-day outcomes for TAVR and SAVR were compared. Finally, outcomes with transfemoral TAVR versus SAVR were compared. Results: In the overall cohort, TAVR was associated with significantly reduced 30-day mortality (odds ratio [OR] TAVR/SAVR =0.60 [0.40–0.91]). Postoperative atrial fibrillation, pneumonia, pleural effusion, renal failure, and bleeding also occurred less frequently with TAVR. Stroke/transient ischemic attack (TIA; OR TAVR/SAVR , 2.03 [1.09–3.77]) and pacemaker implantation (OR TAVR/SAVR , 1.62 [1.21–2.17]) were higher with TAVR. Propensity-matched analysis yielded similar results as the overall cohort. Following stratification by era, TAVR versus SAVR was associated with reduced 30-day mortality in the contemporary but not early era (OR Early , 0.78 [0.48–1.28]; OR Contemporary , 0.31 [0.14–0.65]). Pacemaker implantation was higher with TAVR versus SAVR in both eras (OR Early , 1.60 [1.03–2.46]; OR Contemporary , 1.64 [1.10–2.45]). There was also a nonsignificant trend towards increased stroke/TIA with TAVR during both eras (OR Early , 1.39 [0.58–3.36]; OR Contemporary , 2.46 [0.99–6.10]). Finally, transfemoral TAVR (N=1369) versus SAVR revealed similar findings as the overall cohort; however, the association of TAVR with stroke/TIA was not statistically significant (OR Stroke/TIA , 1.57 [0.79–3.09]). Conclusions: TAVR provides an effective and evolving alternative to SAVR for radiation-associated severe aortic stenosis and was associated with lower 30-day mortality and postoperative complications. TAVR was associated with increased pacemaker implantation and a trend towards increased stroke/TIA. In this unique population with extensive valvular and vascular calcifications, the risk of stroke/TIA with TAVR requires careful consideration and further investigation.

Outcomes of transcatheter vs. isolated surgical aortic valve replacement in mediastinal radiation-associated severe aortic stenosis

Introduction Mediastinal radiation can lead to long-term cardiac sequelae, including aortic valve disease. Surgical aortic valve replacement (SAVR) is associated with poor outcomes in this population. Transcatheter aortic valve replacement (TAVR) now provides an alternative treatment strategy that may improve outcomes. Purpose To compare 30-day outcomes after TAVR vs. isolated SAVR for radiation-associated severe symptomatic aortic stenosis using the Society of Thoracic Surgery (STS) National Adult Cardiac Surgery Database. Methods We evaluated 1,668 TAVR and 2,611 isolated SAVR patients enrolled in the STS national database from July 2011 through December 2018. A propensity score for TAVR vs. SAVR was derived using a non-parsimonious logistic regression model that included 29 pre-operative variables and was used to generate a 1:1 matched cohort (NTotal=1,560). 30-day outcomes in TAVR vs. SAVR patients were compared in the matched cohort using conditional logistic regression. We also tested for temporal trends in 30-day mortality separately for TAVR and SAVR in the matched cohort, adjusted for potential confounders, to see if outcomes varied across the study period. Results In the propensity-matched cohort, baseline demographics, comorbidities and preoperative characteristics were balanced between the TAVR and SAVR groups. The mean age was 73.3 years and 75% were females in each group. In the propensity-matched cohort, TAVR was associated with significantly reduced 30-day all-cause [OR=0.50 (0.30–0.84), p=0.01] and cardiovascular mortality as compared to SAVR [OR=0.33 (0.14–0.78), p=0.01]. Similarly, post-operative complications occurred less in the TAVR group except for stroke/transient ischemic attack (TIA) [OR=3.17 (1.27–7.93), p=0.01] and pacemaker implantation [OR=1.71 (1.21–2.44), p=0.003] which were significantly higher with TAVR (Figure 1A). While, 30-day mortality associated with both procedures improved over the course of the study, the trend was only statistically significant in the TAVR group following adjustment for potential confounders. TAVR was consistently associated with better survival than SAVR in the matched cohort across the study period (Figure 1B). Conclusion Our findings suggest that TAVR is a safe alternative to SAVR for radiation-associated severe symptomatic aortic stenosis and is associated with lower 30-day mortality and post-operative complications. The risk of stroke/TIA and pacemaker implantation is higher with TAVR and should be considered when choosing therapy. Additional prospective studies to validate our findings and evaluate long-term outcomes are needed to further guide clinical decision making in this population. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Funding to support acquisition of the data from the Society of Thoracic Surgery was obtained from discretionary funds available to Dr. Anju Nohria from the Cardiovascular Medicine Division.