Transcatheter Compared With Surgical Aortic Valve Replacement in Patients With Previous Chest-Directed Radiation Therapy

JACC CardioOncol. 2021 Sep 21;3(3):397-407. doi: 10.1016/j.jaccao.2021.07.005. eCollection 2021 Sep.

Abstract

Background: Cardiac surgery for radiation-induced valvular disease is associated with adverse outcomes. Transcatheter aortic valve replacement (TAVR) is increasingly used in patients with a history of chest-directed radiation therapy and aortic stenosis (CRT-AS).

Objectives: We examined outcomes of TAVR compared with surgical aortic valve replacement (SAVR) for patients with CRT-AS.

Methods: We identified 69 patients with CRT-AS who underwent TAVR from January 2012 to September 2018. Operative mortality, postoperative morbidities, and length of hospitalization were compared with 117 contemporaneous patients with CRT-AS who underwent isolated SAVR. Age-adjusted survival was evaluated by means of Cox proportional hazards modeling.

Results: Compared with SAVR patients, TAVR patients were older (mean age 75 ± 11.5 vs 65 ± 11.5 years), with more comorbidities, such as chronic obstructive pulmonary disease, atrial fibrillation, and peripheral vascular disease (all P < 0.050). Operative mortality was 4.3% for SAVR vs 1.4% for TAVR (P = 0.41). Most SAVR deaths (4 of 5) occurred in the intermediate-/high-risk group (Society for Thoracic Surgeons predicted risk of operative mortality >3%; P = 0.026). The ratio of observed to expected mortality was better for low-risk SAVR patients and all TAVR patients (0.72 [95% confidence interval [CI]: 0.59-0.86] and 0.24 [95% CI: 0.05-0.51], respectively) compared with intermediate-/high-risk SAVR patients (2.52 [95% CI: 0.26-4.13]). SAVR patients had significantly longer median intensive care unit and overall length of stay and higher blood transfusion requirements but similar rates of stroke and pacemaker implantation.

Conclusions: TAVR was associated with excellent in-hospital outcomes and better survival compared with intermediate-/high-risk SAVR in patients with CRT-AS. While SAVR still has a role in low-risk patients or those for whom TAVR is unsuitable for technical or anatomical reasons, TAVR is emerging as the standard of care for intermediate-/high-risk CRT-AS patients.

Keywords: CKD, chronic kidney disease; CRT-AS, chest-directed radiation therapy and aortic stenosis; EMR, electronic medical record; ICU, intensive care unit; IPT, inverse probability of treatment; LOS, length of stay; O/E, observed/expected; PPM, permanent pacemaker; PROM, predicted risk of operative mortality; SAVR, surgical aortic valve replacement; STS, Society for Thoracic Surgeons; TAVR, transcatheter aortic valve replacement; outcomes; thoracic oncology; valvular disease.