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Outcomes of TAVR in Patients With Cardiac Amyloid
Study Questions:
What are the outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS) and cardiac amyloid?
Methods:
This study examined patients aged ≥75 years with severe AS referred for TAVI at two sites, and performed blinded bone scintigraphy prior to TAVI to determine presence of cardiac amyloid. Patients with vs. without cardiac amyloid were compared with regard to baseline characteristics and outcomes (periprocedural and mortality) following TAVI.
Results:
There were 200 patients with severe AS enrolled in the study, and cardiac amyloid was diagnosed in 26 (13%). A total of 149 patients (75%) underwent TAVI. Median follow-up was 19 months, with mortality in 42 individuals (21%). Patients with (vs. without) cardiac amyloid were older (88 ± 5 vs. 85 ± 5 years), had lower quality of life (EQ-5D-5L scores of 50 vs. 65), increased left ventricular wall thickness (14 vs. 13 mm), and higher pro-B-type natriuretic peptide values (3702 vs. 1254 ng/L) (p < 0.05 for each). There were no differences in AS severity on echocardiography between groups (p = NS). TAVI periprocedural complications were similar between patients with vs. without cardiac amyloid (38% vs. 35%, p = 0.82), and there was no difference in mortality at follow-up (23% vs. 21%, p = 0.71). When compared to medical management, TAVI was associated with improved outcomes in the overall group (p < 0.001) as well as in the cohort with cardiac amyloid (p = 0.03).
Conclusions:
Cardiac amyloid is common in older patients with severe AS. Following TAVI, procedural complications and mortality were similar in patients with and without cardiac amyloid. TAVI was associated with improved outcomes in patients with severe AS and cardiac amyloid.
Perspective:
The combination of severe AS and cardiac amyloid is common in older patients. While TAVI has been demonstrated to improve survival in many groups with severe AS, outcomes of TAVI in patients with both severe AS and cardiac amyloid were not previously established. This manuscript finds that cardiac amyloid is seen in more than one in five individuals ≥75 years of age with severe AS. While there were differences in baseline characteristics, there were no differences in periprocedural complications or follow-up mortality, and patients with severe AS and cardiac amyloid had improved outcomes compared to those who were medically managed. This paper suggests that individuals with severe symptomatic AS and cardiac amyloid should be considered for TAVI and may experience a survival benefit.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Amyloid, Amyloidosis, Aortic Valve Stenosis, Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Natriuretic Peptide, Brain, Peptide Fragments, Quality of Life, Radionuclide Imaging, Transcatheter Aortic Valve Replacement
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