Transcatheter aortic valve replacement in patients with a history of cancer: Periprocedural and long-term outcomes

Outcomes of patients with active cancer after transcatheter aortic valve replacement: an updated meta-analysis

BACKGROUND

Patients with active cancer and aortic stenosis may be under-referred for valve interventions due to concerns over a prohibitive risk. However, whether active cancer impacts outcomes after transcatheter aortic valve replacement (TAVR) remains unknown.

METHODS

We searched PubMed, Embase, and Cochrane Library in December 2023 for studies comparing the post-TAVR outcomes of patients with versus without active cancer. We pooled odds ratios (OR) and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) applying a random-effects model. Statistical analyses were performed in R version 4.3.2.

RESULTS

We included nine observational studies analyzing 133,906 patients, of whom 9,792 (7.3%) had active cancer. Compared with patients without cancer, patients with active cancer had higher short- (OR 1.33; 95% CI 1.15-1.55; p < 0.001) and long-term mortality (OR 2.29; 95% CI 1.80-2.91; p < 0.001) rates, not driven by cardiovascular mortality (OR 1.30; 95% CI 0.70-2.40; p = 0.40), and higher major bleeding rates (OR 1.66; 95% CI 1.15-2.42; p = 0.008). The higher mortality rate was sustained in an adjusted analysis (aHR 1.77; 95% CI 1.34-2.35; p < 0.001). There was no significant difference in cardiac, renal, and cerebral complications at a follow-up ranging from 180 days to 10 years.

CONCLUSION

Patients with active cancer undergoing TAVR had higher non-cardiovascular mortality and bleeding rates, with comparable incidences of other complications. This highlights the need for a shared decision and appropriate patient selection considering cancer type, staging, bleeding risk, and optimal timing for intervention.

Post-TAVR conduction abnormalities leading to permanent pacemaker implantation: Risk factors, prevention, and management

Transcatheter aortic valve replacement (TAVR) often leads to conduction abnormalities, necessitating pacemaker implantation. This review of 38 meta-analyses identified preexisting right bundle branch block (RBBB), LAHB, and new-onset left bundle branch block as key risk factors, with a higher PPM risk in male and older patients. Procedural factors like transfemoral access and self-expandable valves also increase this risk. Prevention focuses on tailoring TAVR to individual electrophysiological and anatomical profiles. However, there's a lack of consensus in managing these conduction disturbances post-TAVR, highlighting the need for further research and standardized treatment strategies.

Interventional Cardio-Oncology: Unique Challenges and Considerations in a High-Risk Population

OPINION STATEMENT

Patients with cancer are at risk of developing cardiovascular disease (CVD) including atherosclerotic heart disease (AHD), valvular heart disease (VHD), and atrial fibrillation (AF). Advances in percutaneous catheter-based treatments, including percutaneous coronary intervention (PCI) for AHD, percutaneous valve replacement or repair for VHD, and ablation and left atrial appendage occlusion devices (LAAODs) for AF, have provided patients with CVD significant benefit in the recent decades. However, trials and registries investigating outcomes of these procedures often exclude patients with cancer. As a result, patients with cancer are less likely to undergo these therapies despite their benefits. Despite the inclusion of cancer patients in randomized clinical trial data, studies suggest that cancer patients derive similar benefits of percutaneous therapies for CVD compared with patients without cancer. Therefore, percutaneous interventions for CVD should not be withheld in patients with cancer, as they may still benefit from these procedures.

Trends and Outcomes of TAVI and SAVR in Cancer and Noncancer Patients: A Nationwide Analysis

Background

Patients with severe aortic stenosis and cancer are often denied surgical aortic valve replacement (SAVR) due to a prohibitive risk of perioperative mortality.

Objectives

The purpose of this study was to determine the safety of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and cancer.

Methods

The Nationwide Inpatient Sample database (2002-2018) was used to study the outcomes of TAVI vs SAVR in patients with active or prior history of prostate, lung, colorectal, breast, and renal cancer. A propensity score-matched analysis to calculate adjusted odds ratios (aORs) for major adverse cardiovascular events (MACEs) and its components.

Results

A total of 1,505,995 crude population and a subset of 345,413 noncancer and 33,565 cancer patients were selected on propensity score-matched analysis. The yearly trend showed a steep increase in the utilization of TAVI. Compared with SAVR, TAVI had a lower risk of in-hospital mortality in prostate cancer, while there was no difference among other cancer types. Patients with lung (aOR: 0.65; 95% CI: 0.43-0.97) and prostate cancer (aOR: 0.79; 95% CI: 0.66-0.96) had lower, while colorectal cancer (aOR: 1.43; 95% CI: 1.08-1.90) had higher odds of MACE with TAVI. The incidence of major bleeding was lower with TAVI (except for lung cancer), while the risk of stroke was similar (except for colorectal cancer) between TAVI and SAVR.

Conclusions

TAVI in patients with prostate, breast, lung, and renal cancer appears to be a reasonable alternative to SAVR with lower or similar risks of mortality and MACE.

Mortality after transcatheter aortic valve replacement for aortic stenosis among patients with malignancy: a systematic review and meta-analysis

BACKGROUND

With advancements in cancer treatment, the life expectancy of oncology patients has improved. Thus, transcatheter aortic valve replacement (TAVR) may be considered as a feasible option for oncology patients with severe symptomatic aortic stenosis (AS). We aim to evaluate the difference in short- and long-term all-cause mortality in cancer and non-cancer patients treated with TAVR for severe AS.

METHODS

Medline, PubMed, and Cochrane Central Register of Controlled Trials were searched for relevant studies. Patients with cancer who underwent treatment with TAVR for severe AS were included and compared to an identical population without cancer. The primary endpoints were short- and long-term all-cause mortality.

RESULTS

Of 899 studies included, 8 met inclusion criteria. Cancer patients had significantly higher long-term all-cause mortality after TAVR when compared to patients without cancer (risk ratio [RR] 1.43; 95% confidence interval (CI) 1.26-1.62; P < 0.01). Four studies evaluated short-term mortality after TAVR and demonstrated no difference in it in patients with and without cancer (RR 0.72; 95% CI 0.47-1.08; P = 0.11).

CONCLUSION

Patients with cancer and severe AS have higher long-term all-cause mortality after TAVR. However, we found no difference in short-term all-cause mortality when comparing patients with and without cancer. The decision to perform TAVR in cancer patients should be individualized based on life expectancy and existing co-morbidities.