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Yasmin F, Moeed A, Alam MT, Virwani V, Khabir Y, Shaikh A, Vyas AV, Alraies MC. Outcomes after transcatheter aortic valve replacement in cancer survivors with prior chest radiation therapy: an updated systematic review and meta-analysis. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:61. [PMID: 39267144 PMCID: PMC11391771 DOI: 10.1186/s40959-024-00265-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 09/05/2024] [Indexed: 09/14/2024]
Abstract
Clinical outcomes for TAVR in cancer survivors with prior chest radiation therapy (C-XRT) who develop symptomatic aortic-valve stenosis are not adequately assessed in major clinical trials leading to conflicting results. Hence, we conducted this meta-analysis to evaluate the, safety, efficacy, and mortality outcomes of cancer survivors with prior C-XRT undergoing TAVR. MEDLINE and Scopus were searched up to March 2024. Observational studies and randomized controlled trials comparing severe aortic stenosis patients with and without prior C-XRT undergoing TAVR with at least one outcome of interest were shortlisted. Data were analyzed using random-effects model to derive weighted mean differences, and risk ratios with 95% confidence intervals. Six studies with 6,191 patients (278 C-XRT and 5,913 no-C-XRT) were included. All-cause mortality at 30-day (RR 1.63, p = 0.12) and 1-year interval (RR 1.59, p = 0.08) showed no significant differences with prior C-XRT versus no-C-XRT. Worsening CHF was the only post-procedural safety outcome significantly higher in patients with prior C-XRT (RR 1.98, p = 0.0004) versus no- C-XRT. The efficacy end-points i.e., improvement in LVEF (MD 1.24; -0.50, 2.98), and aortic valve gradient (MD -0.63; -1.32, 0.05) were not significantly different. TAVR has similar all-cause mortality, efficacy and safety (except CHF worsening) among cancer survivors with and without a prior history of C-XRT.
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Affiliation(s)
- Farah Yasmin
- Yale University School of Medicine, New Haven, CT, 06511, USA.
- Yale School of Medicine, New Haven, CT, 06511, USA.
| | - Abdul Moeed
- Dow University of Health Sciences, Karachi, PK, Pakistan
| | | | | | - Yumna Khabir
- Dow University of Health Sciences, Karachi, PK, Pakistan
| | - Asim Shaikh
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Apurva V Vyas
- Lehigh Valley Heart and Vascular Institute, Allentown, PA, USA
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Leedy D, Elison DM, Farias F, Cheng R, McCabe JM. Transcatheter aortic valve intervention in patients with cancer. Heart 2023; 109:1508-1515. [PMID: 37147132 DOI: 10.1136/heartjnl-2022-321396] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/16/2023] [Indexed: 05/07/2023] Open
Abstract
The prevalence of concurrent cancer and severe aortic stenosis (AS) is increasing due to an ageing population. In addition to shared traditional risk factors for AS and cancer, patients with cancer may be at increased risk for AS due to off-target effects of cancer-related therapy, such as mediastinal radiation therapy (XRT), as well as shared non-traditional pathophysiological mechanisms. Compared with surgical aortic valve replacement, major adverse events are generally lower in patients with cancer undergoing transcatheter aortic valve intervention (TAVI), especially in those with history of mediastinal XRT. Similar procedural and short-to-intermediate TAVI outcomes have been observed in patients with cancer as compared with no cancer, whereas long-term outcomes are dependent on cancer survival. Considerable heterogeneity exists between cancer subtypes and stage, with worse outcomes observed in those with active and advanced-stage disease as well as specific cancer subtypes. Procedural management in patients with cancer poses unique challenges and thus requires periprocedural expertise and close collaboration with the referring oncology team. The decision to ultimately pursue TAVI involves a multidisciplinary and holistic approach in assessing the appropriateness of intervention. Further clinical trial and registry studies are needed to better appreciate outcomes in this population.
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Affiliation(s)
- Douglas Leedy
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - David M Elison
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Francisco Farias
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Richard Cheng
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
| | - James M McCabe
- Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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Mohanty BD, Coylewright M, Sequeira AR, Shin D, Liu Y, Li D, Fradley M, Alu MC, Mack MJ, Kapadia SR, Kodali S, Thourani VH, Makkar RR, Leon MB, Malenka D. Characteristics and clinical outcomes in patients with prior chest radiation undergoing TAVR: Observations from PARTNER-2. Catheter Cardiovasc Interv 2022; 99:1877-1885. [PMID: 35289473 DOI: 10.1002/ccd.30154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/25/2022] [Accepted: 02/21/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The purpose of this study is to investigate the viability of transcatheter aortic valve replacement (TAVR) for severe symptomatic aortic stenosis (AS) in patients with prior chest radiation therapy (cXRT). BACKGROUND Since patients with prior cXRT perform poorly with surgical aortic valve replacement, TAVR can be a viable alternative. However, clinical outcomes after TAVR in this patient population have not been well studied. METHODS From the pooled registry of the placement of aortic transcatheter valves II trial, we identified patients with and without prior cXRT who underwent TAVR (n = 64 and 3923, respectively). The primary outcome was a composite of all-cause death and any stroke at 2 years. Time to event analyses were shown as Kaplan-Meier event rates and compared by log-rank testing. Hazard ratios (HRs) were estimated and compared by Cox proportional hazards regression model. RESULTS There was no significant difference in the primary outcome between the patients with and without prior cXRT (30.7% vs. 27.0%; p = 0.75; HR, 1.08; 95% confidence interval, 0.66-1.77). Rates of myocardial infarction, vascular complications, acute kidney injury, or new pacemaker implant after TAVR were not statistically different between the two groups. The rate of immediate reintervention with a second valve for aortic regurgitation after TAVR was higher among the patients with prior cXRT. However, no further difference was observed during 2 years follow-up after discharge from the index-procedure hospitalization. CONCLUSIONS TAVR is a viable alternative for severe symptomatic AS in patients who had cXRT in the past.
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Affiliation(s)
- Bibhu D Mohanty
- Department of Cardiovascular Sciences, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Megan Coylewright
- Department of Cardiology, Erlanger Health System, Chattanooga, Tennessee, USA
| | - Ashton R Sequeira
- Department of Internal Medicine,Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Doosup Shin
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Yangbo Liu
- Cardiovascular Research Foundation, New York City, New York, USA
| | - Ditian Li
- Cardiovascular Research Foundation, New York City, New York, USA
| | - Michael Fradley
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria C Alu
- Structural Heart and Valve Center, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, New York, USA
| | - Michael J Mack
- Cardiothoracic Surgery Service, Baylor Scott & White Healthcare, Plano, Texas, USA
| | - Samir R Kapadia
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Susheel Kodali
- Structural Heart and Valve Center, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, New York, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Raj R Makkar
- Interventional Cardiology Division, Los Angeles, California, USA
| | - Martin B Leon
- Structural Heart and Valve Center, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, New York, USA
| | - David Malenka
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is a common comorbidity in patients with cancer. We review shared risk factors between the two diseases and cancer treatments that increase the risk of CAD. We also discuss outcomes and management considerations of patients with cancer who develop CAD. RECENT FINDINGS Several traditional and novel risk factors promote the development of both CAD and cancer. Several cancer treatments further increase the risk of CAD. The presence of cancer is associated with a higher burden of comorbidities and thrombocytopenia, which predisposes patients to higher bleeding risks. Patients with cancer who develop acute coronary syndromes are less likely to receive timely revascularization or appropriate medical therapy, despite evidence showing that receipt of these interventions is associated with substantial benefit. Accordingly, a cancer diagnosis is associated with worse outcomes in patients with CAD. The risk-benefit balance of revascularization is becoming more favorable due to the improving prognosis of many cancers and safer revascularization strategies, including shorter requirements for dual antiplatelet therapy after revascularization. SUMMARY Several factors increase the complexity of managing CAD in patients with cancer. A multidisciplinary approach is recommended to guide treatment decisions in this high-risk and growing patient group.
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