ABSTRACT
BACKGROUND: Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR. METHODS: This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy. RESULTS: Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin's lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p<0.01) and MACE (XRT: 57%; non-XRT: 27%, p<0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48 %; non-XRT: 2.4%, p<0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p=0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p=0.003), poor renal function (HR: 1.29, p<0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival. CONCLUSIONS: Cancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.
ABSTRACT
PURPOSE: To measure the inter- and intraobserver variability among operators of varying expertise in conducting CT-derived fractional flow reserve (CT FFR) measurements on-site by using structural and fluid analysis and to evaluate differences in reproducibility between two different training methods for end users. MATERIALS AND METHODS: This retrospective analysis of the prospectively enrolled cohort included 22 symptomatic patients who underwent both 320-detector row coronary CT angiography and catheter-derived fractional flow reserve (FFR) within 90 days. Thirteen operators of varying expertise were assigned to one of two training arms: arm 1, on-site training by a specialist in CT FFR technology; arm 2, self-training through use of written materials. After the training, all 13 operators reviewed the CT data and measured CT FFR in 24 vessels in 22 patients. Inter- and intraoperator variability and agreements between CT FFR and catheter-derived FFR measurements were evaluated. RESULTS: The overall intraclass correlation coefficient (ICC) among operators was 0.71 (95% confidence interval: 0.58, 0.83) with a mean absolute difference (± standard deviation) of 0.027 ± 0.022. The operators in arm 2 showed greater interoperator differences than those in arm 1 (0.031 ± 0.024 vs 0.023 ± 0.018; P = .024). Among operators who recalculated CT FFR, the mean CT FFR value did not significantly differ between the first and second calculations (ICC, 0.66; 95% confidence interval: 0.46, 0.87), with the medical specialists producing the lowest intraoperator variability (0.053 ± 0.060). The overall correlation coefficient between CT FFR and catheter FFR was r = 0.61, with a mean absolute difference of 0.096 ± 0.089. CONCLUSION: Good reproducibility of CT FFR values calculated on-site on the basis of structural and fluid analysis was observed among operators of varying expertise. Face-to-face training sessions may cause less variability.© RSNA, 2019Supplemental material is available for this article.
