USA: TAVR has benefits over SAVR in patients who require valve replacement after undergoing mediastinal radiation, suggests a recent study in the journal JACC: Cardiovascular Interventions.
Mediastinal radiation is used for the treatment of different types of malignancies involving the lungs, chest, breast, lymph nodes and mediastinum. However, the therapy might lead to the development of radiation-associated cardiopulmonary disease, aortic stenosis being most common. Exposure to prior radiation in patients with severe aortic stenosis increases risk of long-term mortality following surgical replacement. Transcatheter aortic valve replacement (TAVR) is a reasonable therapeutic strategy for patients with severe aortic stenosis irrespective of their surgical risk. Percutaneous approach makes a better alternative for the treatment of patients with prior mediastinal radiation undergoing surgical replacement having .high peri-operative mortality and morbidity
There is a lack of data comparing outcomes of SAVR versus TAVR in patients with prior mediastinal radiation. To address this knowledge gap, Hani Jneid, Baylor School of Medicine, Houston, Texas, and colleagues evaluated the trends and outcomes of patients with prior mediastinal radiation receiving AVR using a large national administrative claims database.
For the purpose, the researchers queried the National Inpatient Sample database years 2012 to 2017 for hospitalization of patients with prior mediasinal radiation who underwent isolated AVER. The study compared the outcomes of TAVR versus SAVR using multivariable analysis. The main study outcome was in-hospital mortality.
The final analysis included 3,675 hospitalizations for isolated AVR; of whom 59.1% underwent TAVR and 40.9% underwent isolated SAVR.
Key findings of the study include:
TAVR was increasingly performed over time, but there was no significant increase in the rates of utilization of SAVR.
The following factors were independently associated with TAVR utilization: older age, chronic lung disease, coronary artery disease, chronic kidney disease, prior cerebrovascular accidents, prior coronary artery bypass grafting, and larger-sized hospitals, while women were less likely to undergo TAVR.
Compared with SAVR, TAVR was associated with lower in-hospital mortality (1.2% vs. 2.0%, adjusted odds ratio: 0.27).
TAVR was associated with lower rates of acute kidney injury, use of mechanical circulatory support, bleeding and respiratory complications, and shorter length of hospital stay.
TAVR was associated with higher rates of pacemaker insertion.
To summarize -- Compared with SAVR, TAVR was associated with lower in-hospital mortality, lower bleeding and respiratory complications, and shorter length of stay but was associated with higher rates of permanent pacemaker insertion.
"This nationwide observational analysis showed that TAVR is increasingly performed among patients with prior mediastinal radiation," wrote the authors.
"In light of the available data, TAVR can provide a safe alternative treatment option for AVR among patients with prior mediastinal radiation. Further studies exploring the long-term comparative safety and effectiveness of TAVR and SAVR among patients with prior mediastinal radiation are warranted," they concluded.
The study, "Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Prior Mediastinal Radiation," is published in the journal JACC: Cardiovascular Interventions.
DOI: https://www.jacc.org/doi/10.1016/j.jcin.2020.08.010