Malignancies and Aortic Stenosis: Is TAVR Warranted?

This meta-analysis tells us that patients with active malignancies and severe aortic stenosis have a good evolution after transcatheter aortic valve replacement (TAVR), except for a higher rate of pacemaker implantation in the general population.

These patients must not be limited to respite care only, at least as far as aortic stenosis is concerned.

Short-term results after TAVR have the same efficacy and safety that in cancer-free patients. In the long term, malignancy stage does make a difference.

All initial and paradigmatic studies on TAVR systematically excluded patients with any type of malignancy.

Advanced cancer was defined as a stage greater than T2 for the primary tumor, N1 for lymph nodes, and/or M1 for metastases. Researchers also considered whether the malignancy was refractory, relapsing, or recurrent. Mortality 1 year after TAVR was more than twofold higher among patients with advanced disease stages compared with patients with limited disease stages.

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These huge differences in survival at 1 year should be taken into account when making decisions about conducting TAVR on a given patient, but they do not mean that we should routinely exclude the procedure as an alternative for all cancer patients.

Recently published in Open Heart, this meta-analysis pooled 3 studies, with a total of 5162 patients who underwent TAVR. Of these, 7.1% had an active cancer. The most common cancer types were gastrointestinal (22.6%), prostate (18.4%), hematological (17.1%), and breast (14.4%).

After 30 days of follow-up, all-cause mortality was similar among patients with and without active cancer (risk ratio [RR]: 0.92; 95% confidence interval [CI]: 0.53-1.59). These differences became apparent only at 1 year and were driven by advanced-stage patients.

Read also: In Search of the Optimal Depth for Self-Expandable Valves.

The only safety endpoint that was higher among patients with cancer was the need for a permanent pacemaker (RR: 1.29; 95% CI: 1.06-1.58). Frequently used drugs such as methotrexate, 5-fluorouracil, and cisplatin are associated with conduction disorders and might explain the higher pacemaker implantation rates.

Original Title: Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis.

Reference: Bendary A et al. Open Heart. 2020;7:e001131.

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