Thoracic Malignancies and Pulmonary Nodules in Patients under Evaluation for Transcatheter Aortic Valve Implantation (TAVI): Incidence, Follow Up and Possible Impact on Treatment Decision

Abstract

BackgroundTranscatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic valve stenosis who are not eligible for operative replacement and an alternative for those with high surgical risk. Due to high age and smoking history in a high proportion of TAVI patients, suspicious findings are frequently observed in pre-procedural chest computer tomography (CCT).MethodsCCT scans of 484 consecutive patients undergoing TAVI were evaluated for incidentally discovered solitary pulmonary nodules (SPN).ResultsIn the entire study population, SPN ≥ 5 mm were found in 87 patients (18%). These patients were compared to 150 patients who were incidentally collected from the 397 patients without SPN or with SPN < 5 mm (control group). After a median follow-up of 455 days, lung cancer was diagnosed in only two patients. Neither SPN ≥ 5 mm (p = 0.579) nor SPN > 8 mm (p = 0.328) were significant predictors of overall survival.ConclusionsDespite the high prevalence of SPNs in this single center TAVI cohort lung cancer incidence at midterm follow-up seems to be low. Thus, aggressive diagnostic approaches for incidentally discovered SPN during TAVI evaluation should not delay the treatment of aortic stenosis. Unless advanced thoracic malignancy is obvious, the well documented reduction of morbidity and mortality by TAVI outweighs potentially harmful delays regarding further diagnostics. Standard guideline-approved procedure for SPN can be safely performed after TAVI.

Pulmonary Resection for Lung Cancer Following Transcatheter Aortic Valve Implantation for Severe Aortic Valve Stenosis: A Case Report

“…1) Solitary pulmonary nodules are often detected incidentally on chest CT before therapy for severe valvular heart disease, such as TAVI for AS, and some of them are rarely diagnosed as lung cancer. 2) Conversely, preoperative examinations for lung cancer also occasionally reveal cardiovascular disease including valvular heart disease. In the recent report, of 1302 patients who underwent surgery for non-small-cell lung cancer, cardiovascular disease requiring invasive treatment was simultaneously discovered in 33 (3%), including valvular heart disease in 6 (0.5%).…”

Outcomes of incidental findings on multi‐detector computed tomography for transcatheter aortic valve implantation assessment: A single‐centre study and review of the literature

“…Despite this, three patients with lung cancer eventually underwent TAVI, with one patient proceeding after successful remission post‐lung cancer treatment. Nevertheless, the presence of large pulmonary nodules (5 to 8 mm or more) still has a relatively low malignant potential with only 2 out of 87 patients diagnosed with lung cancer during a median follow‐up of 1.25 years in another single‐centre retrospective study . It could be argued that such a finding should not necessarily delay treatment for severe AS as it may not impact survival .…”

“…Such findings may reduce the likelihood of receiving TAVI and delay time from MDCT to the TAVI procedure . Previous studies have focused on the impact of MDCT‐IF on survival, yielding conflicting results . Differences likely reflect variations in the definition of IF, the threshold of reporting findings, and malignant potential of individual findings.…”

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

“…Thoraco-abdominal CT angiography, which is performed for vascular anatomy imaging for procedural preplanning, identified masses highly suspicious for malignancy in 3.8% of the studied group [41]. In another single-center trial on 484 consecutive patients evaluated for TAVR, solitary pulmonary nodules larger than 5 mm were found by CT angiography in 87 patients (18%) [42]; at a median follow-up of 455 days, cancer was confirmed in just 2 patients. The incidental discovery of non-definite cancer lung nodules should prompt an expedited lung nodule workup.…”