Monlezun Dominique J, Hostetter Logan, Balan Prakash, Palaskas Nicolas, Lopez-Mattei Juan, Cilingiroglu Mehmet, Iakobishvili Zaza, Ewer Michael, Marmagkiolis Konstantinos, Iliescu Cezar
Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1451, Houston, TX, 77030, USA.
Global System Analytics & Structures, New Orleans, USA.
Cardiooncology. 2021 Jun 28;7(1):25. doi: 10.1186/s40959-021-00111-0.
Cardiovascular disease (CVD) and cancer are the top mortality causes globally, yet little is known about how the diagnosis of cancer affects treatment options in patients with hemodynamically compromising aortic stenosis (AS). Patients with cancer often are excluded from aortic valve replacement (AVR) trials including trials with transcatheter AVR (TAVR) and surgical AVR (SAVR). This study looks at how cancer may influence treatment options and assesses the outcome of patients with cancer who undergo SAVR or TAVR intervention. Additionally, we sought to quantitate and compare both clinical and cost outcomes for patients with and without cancer.
This population-based case-control study uses the most recent year available National Inpatient Sample (NIS (2016) from the United States Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ). Machine learning augmented propensity score adjusted multivariable regression was conducted based on the likelihood of undergoing TAVR versus medical management (MM) and TAVR versus SAVR with model optimization supported by backward propagation neural network machine learning.
Of the 30,195,722 total hospital admissions, 39,254 (0.13%) TAVRs were performed, with significantly fewer performed in patients with versus without cancer even in those of comparable age and mortality risk (23.82% versus 76.18%, p < 0.001) despite having similar hospital and procedural mortality. Multivariable regression in patients with cancer demonstrated that mortality was similar for TAVR, MM, and SAVR, though LOS and cost was significantly lower for TAVR versus MM and comparable for TAVR versus SAVR. Patients with prostate cancer constituted the largest primary cancer among TAVR patients including those with metastatic disease. There were no significant race or geographic disparities for TAVR mortality.
Comparison of aortic valve intervention in patients with and without cancer suggests that interventions are underutilized in the cancer population. This study suggests that patients with cancer including those with metastasis have similar inpatient outcomes to patients without cancer. Further, patients who have symptomatic AS and those with higher risk aortic valve disease should be offered the benefit of intervention. Modern techniques have reduced intervention-related adverse events, provided improved quality of life, and appear to be cost effective; these advantages should not necessarily be denied to patients with co-existing cancer.
心血管疾病（CVD）和癌症是全球主要的死亡原因，但对于癌症诊断如何影响血流动力学不稳定的主动脉瓣狭窄（AS）患者的治疗选择，人们知之甚少。癌症患者通常被排除在主动脉瓣置换（AVR）试验之外，包括经导管主动脉瓣置换术（TAVR）和外科主动脉瓣置换术（SAVR）试验。本研究旨在探讨癌症如何影响治疗选择，并评估接受SAVR或TAVR干预的癌症患者的预后。此外，我们试图对有癌症和无癌症患者的临床和成本结果进行量化和比较。
这项基于人群的病例对照研究使用了美国卫生与公众服务部医疗保健研究与质量局（AHRQ）提供的最新年份（2016年）全国住院样本（NIS）。基于接受TAVR与药物治疗（MM）以及TAVR与SAVR的可能性，进行了机器学习增强倾向评分调整的多变量回归，并通过反向传播神经网络机器学习进行模型优化。
在30,195,722例住院患者中，共进行了39,254例（0.13%）TAVR手术，即使在年龄和死亡风险相当的患者中，有癌症患者接受TAVR手术的比例也显著低于无癌症患者（23.82%对76.18%，p < 0.001），尽管两者的住院和手术死亡率相似。对癌症患者进行的多变量回归分析表明，TAVR、MM和SAVR的死亡率相似，但TAVR组的住院时间和成本显著低于MM组，与SAVR组相当。前列腺癌患者是接受TAVR手术患者中最主要的原发癌症类型，包括那些有转移疾病的患者。TAVR死亡率在种族或地域方面没有显著差异。
对有癌症和无癌症患者的主动脉瓣干预进行比较表明，癌症患者中干预措施的使用不足。本研究表明，包括有转移的癌症患者在内，癌症患者的住院结局与无癌症患者相似。此外，有症状的AS患者和主动脉瓣疾病风险较高的患者应能从干预中获益。现代技术减少了与干预相关的不良事件，提高了生活质量，且似乎具有成本效益；这些优势不一定应被患有并存癌症的患者所剥夺。
