Cardiac Amyloidosis in Patients With Severe Aortic Stenosis: Not a Good Reason to Say No to Transcatheter Aortic Valve Implantation

The association between cardiac amyloidosis (CA) and aortic stenosis (AS) is quite common among older patients because the prevalence of both conditions increases with age. In fact, it is estimated that 1 in 10 patients with high-gradient severe AS and 1 in 3 patients with low-flow low-gradient AS may have CA. 1 Ternacle J Krapf L Mohty D Magne J Nguyen A Galat A Gallet R Teiger E Côté N Clavel MA Tournoux F Pibarot P Damy T. Aortic stenosis and cardiac amyloidosis: JACC review topic of the week. J Am Coll Cardiol. 2019; 74: 2638-2651 Crossref PubMed Scopus (137) Google Scholar CA is characterized by an infiltrative process with deposition of amyloid fibrils in the myocardium, which can comprise transthyretin (more often in older adults) or immunoglobulin light-chain in patients with myeloma. It results in a restrictive phenotype causing different degrees of impairment in diastolic function and longitudinal systolic function, conduction abnormalities, and ultimately congestive heart failure. Previous studies highlighted the increased perioperative mortality and worse midterm outcomes of patients with CA and AS who undergo surgical aortic valve replacement, thus suggesting a potential role for transcatheter aortic valve replacement (TAVR). 2 Galat A Guellich A Bodez D Slama M Dijos M Zeitoun DM Milleron O Attias D Dubois-Randé JL Mohty D Audureau E Teiger E Rosso J Monin JL Damy T. Aortic stenosis and transthyretin cardiac amyloidosis: the chicken or the egg?. Eur Heart J. 2016; 37: 3525-3531 Crossref PubMed Scopus (87) Google Scholar Notably, patients with significant concomitant cardiomyopathies (including CA) were excluded from the pivotal TAVR trials, 3 Makkar RR Fontana GP Jilaihawi H Kapadia S Pichard AD Douglas PS Thourani VH Babaliaros VC Webb JG Herrmann HC Bavaria JE Kodali S Brown DL Bowers B Dewey TM Svensson LG Tuzcu M Moses JW Williams MR Siegel RJ Akin JJ Anderson WN Pocock S Smith CR Leon MB PARTNER Trial InvestigatorsTranscatheter aortic-valve replacement for inoperable severe aortic stenosis. N Engl J Med. 2012; 366: 1696-1704 Crossref PubMed Scopus (1106) Google Scholar and whether interventional treatment is beneficial in this patient subset on top of optimal medical therapy remains unknown. Transcatheter Aortic Valve Implantation in Cardiac Amyloidosis and Aortic StenosisAmerican Journal of CardiologyVol. 198PreviewAortic stenosis (AS) and cardiac amyloidosis (CA) occur concomitantly in a significant number of patients and portend a higher risk of all-cause mortality. Previous studies have investigated outcomes in patients with concomitant CA/AS who underwent transcatheter aortic valve implantation (TAVI) versus medical therapy alone, but no evidence-based consensus regarding the ideal management of these patients has been established. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Full-Text PDF