Abstract
BackgroundImproved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR.MethodsThis is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy.ResultsOf the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin’s lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p < 0.01) and MACE (XRT: 57%; non-XRT: 27%, p < 0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48%; non-XRT: 2.4%, p < 0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p = 0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p = 0.003), poor renal function (HR: 1.29, p < 0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival.ConclusionsCancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.
Highlights
Radiation therapy is an important therapeutic modality in multiple thoracic and non-thoracic cancers [1, 2]
Smoking and anemia were more common and use of ACE/ ARBs was less frequent in the XRT had higher all-cause mortality (XRT) group
Our study demonstrates that patients who underwent Transcatheter aortic valve replacement (TAVR) with prior chest XRT (C-XRT) for thoracic cancers have poor survival compared to the those who had undergone same procedure
Summary
Radiation therapy is an important therapeutic modality in multiple thoracic and non-thoracic cancers [1, 2]. Chest radiation has been part of standard treatment protocol in various malignancies including lymphoma, breast, lung, Radiation-Induced Valvular Heart Disease (RIVHD) is one of the most common late cardiac complications of CXRT that develops in about 10% of patients undergoing C-XRT. Fossa and colleagues previously reported that 39% of Hodgkin’s lymphoma survivors who underwent C-XRT developed at least moderate to severe aortic stenosis in 12 years of follow up [12]. Another retrospective analysis of C-XRT patients’ with Hodgkin’s lymphoma showed valvular disease in 6.2% of patients after an average 22 years of observation, with aortic stenosis (AS) manifesting in more than a half of these patients [14]. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR
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