Abstract
AimsCardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes.Methods and resultsPatients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1–3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow–Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P < 0.001; 3702 vs. 1254 ng/L, P = 0.001). Gender, comorbidities, 6-min walk distance, AS severity, prevalence of disproportionate hypertrophy, and post-TAVI complication rates (38% vs. 35%, P = 0.82) were the same. At a median follow-up of 19 (10–27) months, there was no mortality difference (P = 0.71). Transcatheter aortic valve implantation significantly improved outcome in the overall population (P < 0.001) and in those with AS-amyloid (P = 0.03).ConclusionsAS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.
Highlights
Aortic stenosis (AS) is common, with nearly 5% of patients aged 75 and over having at least moderate AS.[1,2] Symptomatic severe AS requires treatment, either in the form of surgical or transcatheter aortic valve replacement (TAVI), without which average survival is only 2–3 years.[3,4,5,6,7] Transcatheter aortic valve implantation numbers are increasing worldwide, a trend that is likely to continue due both to the ageing population and the expanding role of the procedure itself to include intermediate[8] and even low-risk populations.[9]
A plasma cell dyscrasia was detected in 6 (23%), necessitating unblinding and a referral to the National Amyloidosis Centre, but following detailed review, AL amyloid was felt unlikely in all cases
TAVI improved outcome significantly in the overall cohort (P < 0.001) and in AS-amyloid alone (P = 0.03) compared to medical management (Figure 3B). These data show that AS-amyloid is common and affects around one in eight elderly patients with severe AS being considered for TAVI
Summary
Aortic stenosis (AS) is common, with nearly 5% of patients aged 75 and over having at least moderate AS.[1,2] Symptomatic severe AS requires treatment, either in the form of surgical or transcatheter aortic valve replacement (TAVI), without which average survival is only 2–3 years.[3,4,5,6,7] Transcatheter aortic valve implantation numbers are increasing worldwide, a trend that is likely to continue due both to the ageing population and the expanding role of the procedure itself to include intermediate[8] and even low-risk populations.[9]. There is a non-invasive diagnostic strategy for ATTR-CA, supported by recent expert consensus recommendations[11,12]: bone scintigraphy (99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid, DPD; 99mTc-pyrophosphate; or 99mTc-hydroxymethylene diphosphonate) coupled with a negative search for a plasma cell dyscrasia.[11,12] Several studies have shown a prevalence of dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) of 14–16% in elderly TAVI patients,[13,14] but outcome data are not yet available. Transcatheter aortic valve implantation in AS-amyloid may be futile if outcome post-TAVI is no better than medical management.[15] The most comprehensive paper showed that AS-amyloid was more common in men and was associated with a low-flow, low-gradient AS.[14,16] recruited patients were more male than typical TAVI populations, the number referred clinically (i.e. with potential bias) is unclear, and bone scintigraphy was performed pragmatically after TAVI, so periprocedural complications preventing recruitment (e.g. mortality) would not be captured.[14]
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