TAVR : A Dazzling Alternative to SAVR for Patients With Prior Mediastinal Radiation

Elbadawi et al. tackle the question of aortic valve replacement in patients with prior mediastinal radiation therapy, an under-represented, yet expanding subset of population. Ionizing radiation is used to provoke direct and indirect damage to DNA leading to cellular death, based on the rationale that cancer cells, characterized by an uncontrolled growth, are more sensitive to this treatment than normal cells. As such, radiation therapy has become a key treatment option leading to a survival benefit, and is applied to as many as one-half of patients with cancer. Overall, the absolute number of cancer survivors who have benefited from radiation therapy has been steadily increasing. Despite its survival benefit, mediastinal radiotherapy can lead to vasculopathy, cardiomyopathy, and pericardial and valvular heart diseases.

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More remains to be done to better treat these patients who have been “burned to be alive.” First, radiotherapy protocols are lacking while the risk of radiation-related long-term complications is correlated to the intensity of the received radiation. Second, the use of administrative claims database prevents any thorough and detailed investigation of the timing and cause of death. Third, patients with concomitant coronary artery disease were excluded and more information is needed for this important subset of patients. Finally, follow-up duration was limited in this study and does not match with the long-term detrimental effect of radiation but also with the bioprosthesis durability assessment, topics that need to be further investigated. Hence, an overestimation of the treatment effect is possible and is further supported by the more frequent use of SAVR in small centers. Notwithstanding, this study provides valuable validation from a large real-world dataset of the current management strategy for severe aortic stenosis among patients with prior chest radiation.