TAVR should not be withheld in older patients with severe aortic stenosis (AS) and cardiac amyloidosis (CA), according to Christian Nitsche, MD, et al., based on new findings published Nov. 9 in the Journal of the American College of Cardiology and being presented at AHA 2020. The findings suggest AS-CA patients have "worse functional capacity, cardiac remodeling pre-procedure, and a trend towards worse prognosis" if not treated with TAVR, but similar outcomes as patients with AS, but not CA, if TAVR is performed.

Nitsche and colleagues looked at three international sites and analyzed data from 407 patients (mean age 83.4 years and 48.8% male) referred for TAVR. A clinical score (RAISE) using left-ventricular Remodeling (hypertrophy/diastolic dysfunction), Age, Injury (hsTnT), Systemic involvement, and Electrical abnormalities (RBBB/low-voltages) was developed to predict AS-CA presence (AUC 0.86, 95%CI 0.78-0.94, p<0.001).

Clinicians were blinded prior to the heart team decision on how to treat, resulting in 333 patients undergoing TAVR (81.6%), 10 undergoing surgical aortic valve replacement (AVR) (2.5%) and 65 undergoing medical management (15.9%). After median follow-up of 1.7 years, 23% of patients had died. Nitsche, et al., noted one-year mortality was worse in all-comers AS-CA compared with those patients with solely AS (24.5 vs. 13.9%, p=0.05). However, TAVR vs. medical management appeared to improve survival in AS-CA patients, with no significant difference between AS-CA and AS-only patients post-procedure (p=0.36).

"Despite blinding clinicians prior to heart team decision, less AS-CA patients underwent TAVR and had overall worse outcomes. However, if AS-CA patients were selected for and received TAVR, their outcomes were indistinguishable from lone AS patients. We therefore conclude that a diagnosis of AS-CA should not preclude patients from TAVR," said Nitsche, et al. They add that "future studies should determine whether [transthyretin-related cardiac amyloidosis] (ATTR)-specific treatment improves survival in patients with AS and ATTR-CA following AVR."

In a related editorial comment, Philippe Pibarot, DVM, PhD, FACC; Patrizio Lancellotti, MD, PhD, FACC; and Jagat Narula, MD, PhD, MACC, write that concomitant CA in severe AS is like the Trojan Horse and "more dangerous if it is not recognized and not dealt with." They note that "the RAISE score ≥2 raises the suspicion for CA and should prompt confirmatory tests." They also reiterate that "the diagnosis of CA in symptomatic patients with severe AS should not preclude or delay the consideration for TAVR. Further, it should trigger the consideration for pharmaco-therapeutic approach targeting of CA."

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: AHA Annual Scientific Sessions, AHA20, Aortic Valve, Ventricular Remodeling, Prealbumin, Transcatheter Aortic Valve Replacement, Area Under Curve, Aortic Valve Stenosis, Heart Valve Prosthesis, Cardiomyopathies, Amyloidosis, Cardiology, Hypertrophy, Prognosis, Prognosis

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