Austria: TAVR in AS-CA Patients

TAVR (transcatheter aortic valve replacement) should not be withheld in AS-CA patients despite the worse clinical presentation, suggests a recent study in the Journal of the American College of Cardiology.

Dual pathology of severe aortic stenosis (AS) and cardiac amyloidosis (CA) is common in older AS patients and can be predicted clinically. AS-CA has worse clinical presentation and unless treated, it trends towards worse prognosis.

Older AS patients are increasingly identified to have cardiac amyloidosis. It is not known whether dual AS-CA has worse outcomes or results in futility of TAVR. Considering this, Christian Nitsche, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria, and colleagues aimed to identify clinical characteristics and outcomes of AS-CA compared to lone AS.

TAVR referrals at three international sites underwent blinded research-corelab 99mTc-DPD bone scintigraphy (Perugini Grade-0 negative, 1–3 increasingly positive) prior to intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain-CA (AL) via tissue biopsy. National registries captured all-cause mortality. The study recruited 407 patients (83.4±6.5 years, 49.8% male).

Key Findings of the Study

• DPD was positive in n=48 (11.8%, Grade-1 3.9% Grade-2/3 7.9%); AL was diagnosed in one Grade-1.
• Grade-2/3 patients had worse functional capacity, biomarkers (NT-proBNP/hsTnT), and bi-ventricular remodeling.
• A clinical score (RAISE) using left-ventricular Remodeling (hypertrophy/diastolic dysfunction), Age, Injury (hsTnT), Systemic involvement, and Electrical abnormalities (RBBB/low-voltages) was developed to predict AS-CA presence.
• Heart Team decision (DPD-blinded) resulted in TAVR (81.6%), surgical-AVR (2.5%), or medical management (15.9%).
• After median 1.7 years, 23% of patients had died. 1-year mortality was worse in all-comers AS-CA (Grade-1-3) than lone AS (24.5 vs 13.9%).
• TAVR improved survival versus medical management with AS-CA survival post-TAVR no different to lone AS.

"Dual pathology of AS-CA is common in older AS patients and can be predicted clinically. AS-CA has worse clinical presentation and a trend towards worse prognosis, unless treated. TAVR should therefore not be withheld in AS-CA," concluded the authors.

The study, "Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis," is published in the Journal of the American College of Cardiology.

DOI: https://www.jacc.org/doi/10.1016/j.jacc.2020.11.006