Author Affiliation: (1) Division of Cardiology, University of Pittsburgh, A-429 Scaife Hall, 200 Lothrop Street, 15213, Pittsburgh, PA, USA (2) Department of Nuclear Medicine and Clinical Physiology, ...Kuopio University Hospital, Kuopio, Finland (a) premsoman@usa.net Article History: Registration Date: 06/14/2019 Received Date: 06/10/2019 Accepted Date: 06/10/2019 Online Date: 06/21/2019 Byline:
Aims
Advances in diagnostic imaging have increased the recognition of coexisting transthyretin cardiac amyloidosis (ATTR‐CA) and severe aortic stenosis (AS), with a reported prevalence between 8–16%. ...In this prospective study, we aimed to evaluate the implications of ATTR‐CA on outcomes after transcatheter aortic valve replacement (TAVR).
Methods and results
At two academic centres, we screened patients with severe AS undergoing TAVR for ATTR‐CA. Using Kaplan–Meier analysis, we compared survival free from death and a combined endpoint of death and first heart failure hospitalization between patients with and without ATTR‐CA. Cox proportional‐hazards models were used to determine the association of ATTR‐CA with these endpoints. The rate of heart failure hospitalization was compared amongst those with and without ATTR‐CA. Overall, 204 patients (83 years, 65% male, Society of Thoracic Surgeons score 6.6%, 72% New York Heart Association class III/IV) were included, 27 (13%) with ATTR‐CA. Over a median follow‐up of 2.04 years, there was no difference in mortality (log rank, P = 0.99) or the combined endpoint (log rank, P = 0.79) between patients with and without ATTR‐CA. In Cox proportional‐hazards models, the presence of ATTR‐CA was not associated with death. However, patients with ATTR‐CA had increased rates of heart failure hospitalization at 1 year (0.372 vs. 0.114 events/person‐year, P < 0.004) and 3 years (0.199 vs. 0.111 events/person‐year, P = 0.087) following TAVR.
Conclusion
In moderate‐risk patients with severe AS undergoing TAVR, there was a 13% prevalence of ATTR‐CA, which did not affect mortality. The observed increase in heart failure hospitalization following TAVR in those with ATTR‐CA suggests the consequences of the underlying infiltrative myopathy.
Non-invasive cardiac imaging allows detection of cardiac amyloidosis (CA) in patients with aortic stenosis (AS). Our objective was to estimate the prevalence of clinically suspected CA in patients ...with moderate and severe AS referred for cardiovascular magnetic resonance (CMR) in age and gender categories, and assess associations between AS-CA and all-cause mortality.
We retrospectively identified consecutive AS patients defined by echocardiography referred for further CMR assessment of valvular, myocardial, and aortic disease. CMR identified CA based on typical late-gadolinium enhancement (LGE) patterns, and ancillary clinical evaluation identified suspected CA. Survival analysis with the Log rank test and Cox regression compared associations between CA and mortality.
There were 113 patients (median age 74 years, Q1-Q3: 62-82 years), 96 (85%) with severe AS. Suspected CA was present in 9 patients (8%) all > 80 years. Among those over the median age of 74 years, the prevalence of CA was 9/57 (16%), and excluding women, the prevalence was 8/25 (32%). Low-flow, low-gradient physiology was very common in CA (7/9 patients or 78%). Over a median follow-up of 18 months, 40 deaths (35%) occurred. Mortality in AS + CA patients was higher than AS alone (56% vs. 20% at 1-year, log rank 15.0, P < 0.0001). Adjusting for aortic valve replacement modeled as a time-dependent covariate, Society of Thoracic Surgery predicted risk of mortality, left ventricular ejection fraction, CA remained associated with all-cause mortality (HR = 2.92, 95% CI = 1.09-7.86, P = 0.03).
Suspected CA appears prevalent among older male patients with AS, especially with low flow, low gradient AS, and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.
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