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Is transaortic valve replacement the modality of choice in patients with chronic lung disease?

Calcific aortic stenosis is the most common heart valve disease in the Western world. Once symptomatic and left untreated, severe aortic valve stenosis has a very poor prognosis, carrying a 25%–50% yearly mortality. Its prevalence increases with age and among the elderly population, and the pooled prevalence of all aortic stenosis is presumed to be around 12.4% with 3.4% baring its most severe form. Historically, surgical aortic valve replacement (SAVR) was the treatment of choice in advance of less invasive approaches; nonetheless prohibited for some patients with extreme surgical risk. Since the first documented transaortic valve replacement (TAVR) by Cribier in 2002, massive efforts have been directed to improve and compare this technique to surgical interventions. Mounting evidence from TAVR landmark clinical trials have finally paved the road for FDA approval throughout the whole surgical risk spectrum; however, individualized risk‐benefit assessment is ultimately the mainstay for treatment selection. Initial assessment by a multidisciplinary heart team is aimed to select those patients where their quality of life is likely to improve with an intervention. Furthermore, the use of screening tools to evaluate the risk‐adjusted outcomes akin to the Society of Thoracic Surgeons (STS) PROM score, allows clinicians to guide appropriate strategies. Chronic obstructive pulmonary disease (COPD) is a common comorbidity that significantly impacts on decision making among candidates for aortic valve replacement, both of which share similar risk factors and cardinal symptoms surrounding functional limitation. A metanalysis from 2016 calculated a burden of COPD from 12.55% to 43.4% and was associated with increased short‐ and midterm cardiac‐cause mortality. COPD is an important component computed in the STS PROM score which elevates the surgical risk even for first‐time isolated aortic valve replacement. There is growing evidence that in this population TAVR is safe and feasible. Data from a large cross‐sectional study regarding high‐surgical‐risk cohorts with concomitant nonstratified COPD severity and severe aortic stenosis, showed that TAVR portended significant fewer respiratory and nonrespiratory complication rates including in‐hospital mortality, major bleeding, acute kidney injury, postoperative sepsis, acute myocardial infarctions, hospital length of stay, and total cost compared with SAVR. However, although TAVR performed better in this population, moderate and severe COPD has been established as an independent predictor of increased early and 1‐year mortality after TAVR. Furthermore, in a study published by Mok et al., among 319 rolling patients receiving TAVR, they found the procedure being futile in more than onethird of patients with concomitant COPD. In this issue of the Journal of Cardiac Surgery, Catalano et al, sought to elucidate the difference in quality improvement patterns post‐TAVR in a cohort comprising only intermediate and high surgical risk for severe aortic stenosis in patients with and without chronic lung disease (defined as having an forced expiratory volume in the first second [FEV1] < 75% predicted on spirometry) using the Kansas City Cardiomyopathy Questionnaire (KCCQ): a 23‐item self‐ administered questionnaire that assesses symptoms, functional status, and quality of life in patients with heart failure. KCCQ higher scores indicate less symptomatic burden; and changes in the KCCQ overall summary score of 5, 10, and 20 points correspond to small, moderate, or large clinical improvement respectively. Not surprisingly, they found that patients with chronic lung disease (CLD) had higher STS PROM scores as compared with patients without lung disease. Although patients with CLD had lower preoperative KCCQ scores than those without lung disease (53.8 ± 23.0 vs. 61.1 ± 22.2, p = .016) they experienced similar and large improvements at 30‐days post‐TAVR compared with patients without CLD (21.5 ± 25.7 vs. 21.9 ± 23.5, p = .900). Further subgroup