Salvador Fuentes-Alexandro

Transcatheter Aortic Valve Replacement (TAVR) in patients with systemic autoimmune diseases

Sir, We read with interest the report by Bert et al. They described a severe critical case where a young woman with systemic lupus erythematosus (SLE) presented with New York Heart Association (NYHA) class IV, acute renal failure and active SLE. During the initial evaluation she was also found to have worsened aortic stenosis (aortic valve area, 0.88 cm; mean aortic valve gradient, 37mm Hg; and peak systolic velocity, 3.7m/ s) and systolic dysfunction with an ejection fraction (EF) of 30%. She underwent transcatheter aortic valve replacement (TAVR) with excellent post-procedural outcome. While this is a common scenario in elderly patients, it is quite infrequent in young patients with autoimmune disease. Therefore, we would like to emphasize a few additional aspects. In the PARTNER trial cohort B (inoperable patients), which randomized patients to TAVR vs. standard therapy, TAVR significantly reduced the rates of death from any cause, rates of the composite end point of death or repeat hospitalization and cardiac symptoms. In fact, the number needed to treat (NNT) to prevent one death was five (20% absolute risk reduction) and the NNT to prevent one death from cardiovascular causes was four (24% absolute risk reduction). However, as Bert et al. clearly stress, not all patients fit in clinical trials, particularly a patient with immunosuppression, dialysis, a functionally bicuspid valve, which can pose geometrical issues that can affect appropriate valve deployment, hypercoagulable state, and acute decompensation of chronic disease. Patients with systemic autoimmune diseases, especially those with antiphospholipid syndrome (APS), have an increased risk of stroke; this makes TAVR even more challenging. TAVR, with the current technology, has a stroke risk in the range of 3–5%. It would be important to know how the stroke was risk-assessed in this patient with active SLE and APS, and what the impact of TAVR was on her mitral regurgitation once her ventricular function and NYHA class improved. This case makes us wonder about a few additional questions: 1) How should stroke risk be assessed in patients with APS undergoing TAVR?; 2) what is the long-term durability of these valves?; 3) what is the impact of SLE on these valves?; 4) should TAVR be the initial approach for patients with SLE and APS on chronic immunosuppressive therapy?; and 5) what should be the preferred periprocedural antithrombotic regimen in patients prone to thrombosis? Currently, TAVR is only approved commercially for inoperable patients in the United States; however, in the near future with newer devices and long-term outcome data from randomized trials and registries, patients with autoimmune diseases who present with significant valvular disease may have a less invasive option that may impact their morbidity and mortality.