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TAVR may be best choice for valve replacement after mediastinal radiation

JACC: Cardiovascular Interventions
Reuters Health - 24/11/2020 - In patients who have previously undergone mediastinal radiation and require aortic-valve replacement, transcatheter aortic-valve replacement (TAVR) appears to offer advantages over surgical aortic-valve replacement (SAVR), according to a large database study.

Compared with SAVR, "TAVR procedures are increasingly performed among patients with prior mediastinal radiation, and . . . they are associated with lower hospital mortality and bleeding and respiratory complications, as well as shorter hospitalization," Dr. Hani Jneid of the Baylor School of Medicine and the Michael E. DeBakey VA Medical Center, in Houston, Texas, told Reuters Health by email.

In a paper in JACC: Cardiovascular Interventions, Dr. Jneid and colleagues note that although mediastinal radiation is an important treatment for malignancies it can lead to radiation-associated cardiopulmonary disease, with aortic stenosis being the most common valvular consequence.

Patients who have undergone mediastinal radiation have been excluded from the pivotal trials comparing TAVR and SAVR, the researchers note. They examined national data on more than 3,600 hospitalizations for isolated aortic-valve replacement between 2012 and 2017; 59% of these patients underwent TAVR and the remaining isolated SAVR.

TAVR patients were more likely to be older, have chronic systolic heart failure, chronic lung disease, chronic kidney disease and coronary-artery disease. They were also more likely to be operated on at bigger hospitals. Women were less likely to receive TAVR than men.

TAVR was associated with lower in-hospital mortality (1.2% vs. 2.0%, P=0.02), mechanical circulatory support (0.2% vs. 1.7%, P<0.001) and a shorter median hospital stay (three vs. six days, P<0.001).

Other advantages included significantly fewer blood transfusions and respiratory complications and less need for discharge to a nursing facility.

TAVR was associated with higher rates of pacemaker insertion (OR, 2.63, P=0.01), however. Median in-hospital charges were also significantly higher.

Overall, say the researchers, "TAVR is increasingly employed for patients with prior mediastinal radiation, while the utilization of SAVR did not significantly increase."

These findings, Dr. Jneid concluded, "suggest that TAVR is a safe alternative treatment option for aortic-valve replacement among patients with prior mediastinal radiation."

Dr. Paul Guedeney, co-author of an accompanying editorial, told Reuters Health by email, "With the largest dataset available to date, this study provides a valuable validation of the current guidelines recommending TAVR as the preferred option in case of severe aortic stenosis in patients with prior chest radiation."

"Nonetheless," concluded Dr. Guedeney of Pitie Salpetriere Hospital, in Paris, "further studies with long-term follow-up are warranted to evaluate if these results remain consistent over a longer time period."

SOURCE: https://bit.ly/3pRPf42 and https://bit.ly/3kQUv41 JACC: Cardiovascular Interventions, online November 16, 2020.

By David Douglas

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