TAVR in Cancer Patients With Severe AS

Study Questions:

How do outcomes of patients with cancer and severe aortic stenosis (AS) who undergo transcatheter aortic valve replacement (TAVR) compare to those without cancer?

Methods:

The investigators interrogated the TOP-AS registry (TAVR in Oncology Patients with severe AS), which enrolled 222 patients with severe AS and an active malignancy undergoing TAVR, and compared their clinical characteristics and outcomes to that of 2,522 patients without cancer who underwent TAVR in five centers participating in the TOP-AS registry during the same time frame. Additional analyses were performed in a 1:4 propensity score matched cohort.

Results:

The 222 cancer patients enrolled had a median age of 79 years, comprised of 60% men, and included a variety of malignancies, the most frequent being gastrointestinal (22%), prostate (16%), breast (15%), hematologic (15%), and lung (11%), with 31% having metastatic cancer, thus representing a high-risk cohort. The goal of therapy was palliative for 37%, and curative for 55% of patients. While cancer patients were more likely to be frail, they were younger, had less cardiovascular comorbidities, and lower Society of Thoracic Surgeons score compared to their counterparts without cancer. Procedural mortality and complication rates were similar between cancer and noncancer patients, except for a higher rate of bleeding with cancer. One-year mortality was higher in cancer patients (15% vs. 9%), with 75% (n = 24) of deaths attributed to noncardiovascular reasons, including 17 due to cancer. The propensity-matched analysis corroborated the full cohort findings, except there were no longer differences in bleeding. Interestingly, when stratified by cancer stage, those with stage I/II cancer did not have a higher risk of death post-TAVR compared to their noncancer matched controls. Stage III/IV cancer pre-TAVR was the strongest predictor of late mortality. Half of the cancer patients were free of heart failure symptoms at 1 year.

Conclusions:

Patients with cancer undergoing TAVR have similar post-procedural outcomes, but worse 1-year prognosis compared to their noncancer counterparts, driven mostly by those with advanced stage cancer.

Perspective:

This study corroborates previous findings suggesting that TAVR is a viable treatment option for patients with severe AS and concurrent malignancy, and an alternative to surgical valve replacement, which has limited use in this subgroup due to increased perioperative mortality. The higher 1-year mortality in stage III/VI cancer patients post-TAVR requires additional consideration, given current guidelines state a life expectancy <12 months should exclude the use of TAVR. However, as novel cancer therapies emerge and malignancies are managed as chronic illnesses, an argument will eventually be made for performing palliative TAVR in patients with advanced stage cancer in whom symptoms can be clearly attributed to severe AS.

Clinical Topics: Cardiac Surgery, Cardio-Oncology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Breast Neoplasms, Cardiac Surgical Procedures, Cardiotoxicity, Chronic Disease, Frail Elderly, Gastrointestinal Neoplasms, Geriatrics, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Lung Neoplasms, Neoplasms, Palliative Care, Prostatic Neoplasms, Transcatheter Aortic Valve Replacement


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