Aortic stenosis and amyloid heart disease: ‘the 2A dangerous liaisons’

This commentary refers to ‘Prevalence and outcome of dual aortic stenosis and cardiac amyloid pathology in patients referred for transcatheter aortic valve implantation’, by P.R. Scully et al., on page 2759. We read with great interest the article by Scully et al. 1 The authors investigated 200 patients aged ≥75 years with severe aortic stenosis (AS) referred for TAVR and showed that transcatheter aortic valve replacement (TAVR) complications and mortality were similar between AS and cardiac amyloidosis (CA) vs. AS alone. Their results are interesting and partially in accordance with previous reports.2–5 However, only 61.5% of AS–CA were treated by TAVR vs. 76% of patients with lone AS. It is surprising that patients with both severe AS and concomitant CA have similar echocardiographic characteristics [except for more left ventricle (LV) hypertrophy] than those with severe AS alone. In particular, LV ejection fraction (LVEF), LV global longitudinal function, diastolic mitral E/A ratio, tricuspid annular plane systolic excursion (TAPSE), and LV stroke volume of patients with AS–CA were similar to that of patients with lone AS, whereas previous studies2–5 report a much higher prevalence of LV diastolic and systolic dysfunction as well as low flow state in patients with AS and CA, compared to those with AS and no CA.2 , 4 In a previous study by Castano et al.,2 the average LVEF was 47.6 ± 17.6 and the mitral E/A ratio was 2.30 (1.10–3.10) in patients with AS–CA vs. 54 ± 11% and 1.28 (0.75–2.15), respectively, in the present study. These findings suggest most likely the presence of selection biases in the actual study, where patients with AS and more advanced CA and associated LV dysfunction were excluded or underrepresented. Hence, the results of the comparison of prognosis between AS–CA and lone AS should be interpreted with great caution.