What do you treat first, valvular heart disease or active cancer?

Cases of patients with both valvular heart disease and active cancer is becoming more common, attendees heard at the Canadian Cardiovascular Congress in Ottawa this October. Treating these cases means choosing what pathway to take and staging how to progress with treatment.“There isn’t a lot of evidence base in this field. A lot is based on clinical judgement,” explained Dr. Nicolo Piazza, co-director of the structural heart disease program at McGill University Health Centre (MUHC) and assistant professor at McGill University. He was one of three experts who discussed cases presented by early career physicians.The growing number of patients with both diseases is in part due to the older population at risk for valvular heart disease is also at higher risk of cancer. Dr. Piazza noted that in clinical trials of transcatheter aortic valve implantation (TAVI), 3.8% to 8.8% of patients have active cancers, where more than 22% have a history of cancer. The mortality related to untreated valve disease is often worse than the active cancer, Dr. Piazza said. He cited a review of issues around TAVI and cancer that was published in Medicina and a review of transcatheter aortic valve replacement (TAVR) and cancer that was published in Reviews of Cardiovascular Medicine.The cardiac imaging needed to investigate valvular disease may also find previously undetected cancer. Dr. Piazza cited one Swiss study published in the American Heart Journal that found 4.5% of 575 work-ups prior to TAVI revealed newly diagnosed active cases of cancer. When it comes to treatment, there are a number of ticking clocks, said Dr. Maral Ouzounian, head of the division of cardiovascular surgery at University Health Network (UHN), cardiac surgeon at UHN's Peter Munk Cardiac Centre and a professor at the University of Toronto. There’s the severity of valvular heart disease and how long it can be left untreated, there’s the time needed to recover from a procedure or surgery and there’s the window of time where cancer treatment needs to be delivered in order to impact prognosis. Here are the stages Dr. Piazza suggested going through when managing these cases:Confirm the severity of the heart valvular diseaseSymptoms such as dyspnea or others may not be completely due to valvular heart disease. Some may be cancer-related and/or due to dehydration, anemia or other comorbidities such as kidney disease. The type of treatment (i.e., TAVI or TAVR or surgical valve replacement) depends on the severity of the valvular heart disease, so it’s important to realize what is attributable to the valve(s) and what is not.Learn about the oncology team’s intent in terms of treatment and the prognosis of the patient’s cancer The oncology team’s plans and prognosis help decide the timing and staging of interventions.If cancer is in the early stages (stage I or II), the odds of early mortality at 180 days or one year following TAVR are similar to those who don’t have cancer, Dr. Piazza said. Those with stage III or IV cancer tend to have more complications due to bleeding and have poor outcomes. He was citing a 2024 meta-analysis published in Cardio-Oncology that also found patients with active cancer undergoing TAVR had no difference in other types of complications compared to patients without cancer. “A cancer diagnosis alone does not exclude anyone from any valve intervention,” Dr. Piazza said. Does valvular heart disease block the chance of cancer treatment? The answer to this is where the entire cardiology and oncology team can assess what pathway to choose. The choices are mainly treat the valve first, do some kind of bridge procedure (i.e, balloon aortic valvuloplasty), treat the cancer first (e.g., if valvular disease is not yet limiting), or offer a palliative procedure, Dr. Piazza noted.“In general, we need to know if the patient would tolerate cancer treatment without valve intervention,” Dr. Ouzounian said.Learn about post-operative bleeding risks, frailty and painThe surgery or procedure is just one hurdle; managing risk of bleeding and ensuring recovery are other challenges in this patient population. “The bleeding is the important potential complication that we should always think about, whether it is periprocedural or long term because many of these have hematologic consequences for the cancer treatments,” Dr. Piazza said. It’s important to plan antithrombotic medications based on the patient’s platelet count. The perioperative risk may be less than the post-operative risk. “These days we can pretty much get everyone out of the OR and into the ICU, but the question is what is the long-term outcome,” said Dr. Richard Cook, director of the minimal access and robotically assisted cardiac surgery at Vancouver General Hospital and a clinical professor at the University of British Columbia.The type of valve (e.g., bioprosthesis valve or mechanical valve) and how it will respond to changing hematologic values during cancer treatment also needs to be considered.How soon after heart valve surgery can patients start cancer treatment?Dr. Cook said that patients can be more mobile following cardiac surgery than previously thought. Cancer treatment can be initiated sooner if the patient has pre-habilitation to get them healthy and as strong as possible before surgery. Nutrition is important too. Having a transcatheter procedure rather than a surgical procedure should also decrease recovery time. In terms of the immune system, chemotherapy could be started as early as a few weeks after cardiac surgery in some cases, Dr. Ouzounian said. It all depends on the type of cardiac surgery or procedure, the anticoagulation regime following surgery and the type of cancer treatment. The main message is that managing cases of valvular heart disease and cancer requires a multidisciplinary approach. “I think this is an area that has been exploding in terms of research, and patients and physicians are dealing with very complex situations that require inputs from specialists coming at it from all different sides,” Dr. Ouzounian said. Right now, these patients receive care in tertiary or quaternary centres, but as evidence grows, there may be more guidance that would allow these patients to get treatment at other centres.

What do you treat first, valvular heart disease or active cancer?

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