Key result
Prior chest radiation in cancer survivors undergoing transcatheter aortic valve replacement was associated with a significantly higher risk of all-cause mortality (HR 2.07) compared to those without prior radiation.
Why the study?
Long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR for severe aortic stenosis were unknown.
Does prior chest ionizing radiation increase all-cause mortality and MACE in patients undergoing TAVR for symptomatic severe aortic stenosis?
Cohort (n=610)
No
Does prior chest ionizing radiation increase all-cause mortality and MACE in patients undergoing TAVR for symptomatic severe aortic stenosis?
Hazard Ratio: 2.07 (95% CI 1.24–3.31)
Absolute Event Rate: 29% vs 15%
p-value: p=0.005
In patients undergoing TAVR for severe aortic stenosis, a history of prior chest radiation is associated with a two-fold increased risk of all-cause mortality and significantly higher rates of MACE and pacemaker implantation.
May inform risk stratification for TAVR in cancer survivors; hypothesis-generating and requires prospective validation.
BACKGROUND: Improved 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. METHODS: This 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. RESULTS: Of 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. CONCLUSIONS: Cancer 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.
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Agrawal et al. (2019) conducted a cohort in Symptomatic severe aortic stenosis (n=610). Prior chest ionizing radiation (C-XRT) vs. No prior chest radiation (non-XRT) was evaluated on All-cause mortality (HR 2.07, 95% CI 1.24-3.31, p=0.005). Prior chest radiation in cancer survivors undergoing transcatheter aortic valve replacement was associated with a significantly higher risk of all-cause mortality (HR 2.07) compared to those without prior radiation.
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