The Onco-cardiologist Dilemma: to Implant, to Defer, or to Avoid Transcatheter Aortic Valve Replacement in Cancer Patients with Aortic Stenosis?

Abstract

Purpose of Review Aging is associated with an increased prevalence of both cancer and heart disease. The progression of aortic valve calcification to aortic stenosis may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy with mediastinal involvement. Symptomatic aortic stenosis is occasionally diagnosed in cancer patients undergoing cardiovascular evaluation; likewise, cancer is often recognized during assessment preceding aortic valve interventions. In these complex cases, physicians face difficult treatment decisions. Due to a myriad of clinical presentations of cancer and valve disease, specific guidelines for this patient population are not currently in place. Management is currently based on clinical judgment, on an individual basis. Recent Findings Patients with cancer in remission or with a favorable prognosis should be treated according to current cardiovascular guidelines. In these patients, aortic valve replacement can be performed either by surgery or transcatheter. Significant challenges arise in patients with active cancer, especially those receiving anti-cancer treatment. Recent data suggests that these patients can be offered aortic valve replacement, with a trend of favoring the transcatheter route in order to minimize perioperative This article is part of the Topical Collection on Cardio-Oncology

Transcatheter aortic valve replacement in patients with severe comorbidities: A retrospective cohort study

“…In daily clinical practice, some patients with severe AS and concomitant malignancy, including advanced metastatic diseases, may be more threatened by AS than by malignancy. Although TAVR may provide a >1‐year life expectancy for patients with an active malignancy, it remains difficult for multidisciplinary heart teams to make treatment recommendation for this patient population 35 . The recent OCEAN‐TAVI registry demonstrated that patients with cancer had a similar 1‐year mortality rate compared to those without 36 .…”

TAVR in cancer; healing the sickest of the sick

“…Cancer patients receive significant mortality benefit with both surgical and transcatheter aortic valve replacement. 1,2 The present meta-analysis demonstrates the important differences between patient with active cancer and cancer survivors. Although short-term mortality is similar between the two groups and patients without cancer, patients with active cancer experience worse long term outcomes.…”

“…Similar to several types of cancer, severe symptomatic aortic stenosis evolved from a terminal condition before the era of SAVR, to a single therapy condition (surgical aortic valve replacements) and today to a treatable condition with several available options. Cancer patients receive significant mortality benefit with both surgical and transcatheter aortic valve replacement 1,2 …”

Active cancer and cardiac surgery: Possible scenarios in patient decision-making

“…Cancer represents a frequent comorbidity in elderly patients requiring cardiac and non-cardiac interventions [21,22]. In these cases, the best approach is not well established because of the lack of evidence-based recommendations [23].…”

“…First of all, before choosing the operative approach, the Heart Team should clarify cancer prognosis with an oncologist, including appropriate cancer staging [23]. While it is reasonable that previous or remitted malignancies are not considered as contraindication to surgery, the presence of active cancer is still matter of debate.…”