TAVR in cancer patients: outcomes in survivors with radiation and active cancer

Heart failure (HF) due to radiation-induced aortic stenosis (AS) is one of the most frequent late complications in cancer survivors with prior chest radiation therapy (C-XRT). Despite advancements in cardiac-sparing radiation techniques, the long-term cardiotoxic effects, particularly valvular heart disease, remain challenging [1]. Aortic stenosis in this population has a poor prognosis, with untreated symptomatic cases leading to very high mortality within two years [2]. While surgical aortic valve replacement (SAVR) is the standard intervention for severe AS, it is often not feasible for patients with prior C-XRT due to radiation-induced mediastinal fibrosis and calcification. Transcatheter aortic valve replacement (TAVR) offers a less invasive alternative, but its outcomes in this high-risk group remain unclear [3]. Key considerations for the management of these patients are outlined in Table 1.

Table 1 TAVR in cancer survivors with prior chest radiation - key considerations

Previous meta-analyses by Zafar et al. (2020) suggested that TAVR in cancer survivors with prior C-XRT had comparable short-term (30-day) mortality and safety outcomes to non-C-XRT patients [4]. However, the study revealed a higher 1-year mortality rate and a significant increase in congestive heart failure (CHF) exacerbation in the C-XRT group. Building on these findings, two new meta-analyses by Felix et al [5]. and Yasmin et al. [6], in this issue, offer fresh perspectives on TAVR outcomes in C-XRT patients. Yasmin et al.’s analysis of 6,191 patients demonstrated no significant differences in all-cause mortality at 30 days and 1 year between C-XRT and non-C-XRT patients, but a substantially higher risk of worsening CHF post-procedure (RR 1.98, p = 0.0004). Felix et al. studied outcomes after TAVR in patients with or without active cancers and found higher short- and long-term mortality rates driven by non-cardiovascular causes in patients with active cancer. There was also a higher incidence of post-TAVR major bleeding in patients with active cancer, not driven by major vascular complications, highlighting the need for a personalized approach and early intervention due to the progressive nature of radiation-induced valvular disease.

When considered together, these studies emphasize the need for clinical evaluation and multidisciplinary decision-making when selecting candidates for TAVR among cancer patients. For those with active cancer, as discussed by Felix et al., careful assessment of cancer stage, bleeding risk, and overall prognosis is important. For cancer survivors with prior C-XRT, as shown by Yasmin et al., the focus is on managing potential radiation-related cardiotoxicity and its impact on post-procedural outcomes. These studies provide valuable data to guide patient selection and optimize procedural outcomes in cancer patients undergoing TAVR.

The collective findings underscore that while TAVR is a viable option for cancer survivors with prior C-XRT, the increased risk of heart failure exacerbation necessitates careful management. Both Felix et al. and Yasmin et al. emphasize the importance of tailored strategies, particularly individualized approaches, early intervention, and close monitoring, to address the higher risk of CHF. A multidisciplinary approach, involving oncologists in treatment decisions, is essential for optimizing patient outcomes in this unique population.

Despite their valuable contributions, both studies face limitations that must be acknowledged. Yasmin et al. point out the difficulty of analyzing a heterogeneous patient population, with varying types of thoracic malignancies, therapies, and comorbidities. They also note significant gaps in data, including the inability to evaluate radiation dosage, tumor location, and the interval between radiation therapy and TAVR. Similarly, Felix et al. encountered challenges in analyzing data related to cancer type, surgical risk, and device use, which limits the generalizability of their findings. Both studies underscore the need for large-scale, randomized controlled trials (RCTs) to provide conclusive evidence on the efficacy and safety of TAVR in this underrepresented population.

In conclusion, while TAVR offers considerable potential for cancer survivors with severe AS and prior C-XRT, managing the increased risk of heart failure exacerbation requires an individualized approach. Close post-procedural monitoring, risk assessment models that consider cancer-specific factors, and collaboration across specialties are essential for improving patient outcomes. Future RCTs are critical to refining risk stratification and establishing clear guidelines for managing these high-risk patients.