Aortic valve replacement in patients with preexisting liver disease: Transfemoral approach with favorable survival

Abstract

IntroductionThe treatment of aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), but the experience in patients with liver disease is limited. To address this open question, we report the outcome of patients with liver disease undergoing surgical aortic valve replacement (SAVR), transapical (TA), and transfemoral (TF) TAVR.Methods and ResultsBetween January 2004 and August 2016, 4,394 patients received aortic valve replacement at our institution. We identified 85 patients (mean follow‐up 504 ± 733 days, age 73.4 ± 9.2 years, 44.7% female) with preexisting liver disease (median model of end‐stage liver disease score 11, MELD‐Na), who underwent TF‐TAVR (n = 30), TA‐TAVR (n = 13), or SAVR (n = 42). Baseline Society of Thoracic Surgeons Predicted Risk of Mortality (STS‐PROM) and of Mortality and Morbidity (STS‐PROMM) were the lowest in SAVR patients (related to TF‐ and TA‐TAVR, both p < 0.01). Operative mortality (18.8%) was high, but no procedure showed superior short‐term outcome. Need for renal replacement therapy (31.5% vs. 10.3%, p = 0.046) and reoperation occurred more frequently after SAVR than after TF‐TAVR (26.6% vs. 6.7%, p = 0.021). Moreover, TF‐TAVR patients had superior long‐term survival compared to SAVR (log‐rank test p = 0.048 and Cox regression adjusted for MELD and STS‐PROM, p = 0.01, HR 0.25, CI95 0.09–0.71). Baseline MELD‐Na (p = 0.013) and STS PROMM (p = 0.01) were predictors for operative mortality (ROC‐analysis).ConclusionsOur results indicate increased perioperative risks for patients with liver disease undergoing AVR, but favorable long‐term survival after TF‐TAVR compared to SAVR. For baseline risk, stratification in patients with liver disease undergoing AVR, MELD‐Na and STS‐PROMM are valuable predictors.

Outcomes of transcatheter aortic valve replacement in end stage liver and renal disease

“…Though TAVR is an appealing alternative for high risk surgical patients, 19‐22 some studies suggest patients with ESLD and ESRD have higher mortality rates post‐TAVR when compared with patients without these comorbidities. Previous studies in patients with cirrhosis who underwent TAVR demonstrated in‐hospital mortality rates between 9 and 36%, and 1 year mortality rates between 36 and 67% 10,11 .…”

“…In patients with ESLD and ESRD, TAVR has emerged as a potential alternative to surgery, 1,6-8,13,19-21 however, there remains few studies evaluating clinical and echocardiographic outcomes after TAVR in patients pretransplant with ESLD and ESRD. [12][13][14] Though TAVR is an appealing alternative for high risk surgical patients, [19][20][21][22] cirrhosis who underwent TAVR demonstrated in-hospital mortality rates between 9 and 36%, and 1 year mortality rates between 36 and 67%. 10,11 Comparatively, this study had no in hospital deaths for the 15 patients with cirrhosis and only a 7.1% mortality rate at 1-year.…”

Prognostic value of the dynamic hepatorenal function on intermediate‐term mortality in TAVI patients with survival to discharge

“… 7 , 8 , 9 However, liver function is underappreciated, with a few studies focusing on liver function only in patients with pre‐existing liver diseases. 10 , 11 , 12 , 13 Despite many studies emphasizing the prognostic value of the combination of renal and liver function on varied types of cardiac pathologies, 14 , 15 , 16 , 17 , 18 , 19 , 20 there is a paucity of data on TAVI. Moreover, it remains to be seen which part of patients are more likely to derive hepatorenal function improvement from TAVI, and how this benefit influences intermediate‐term mortality.…”

“…[7][8][9] However, liver function is underappreciated, with a few studies focusing on liver function only in patients with pre-existing liver diseases. [10][11][12][13] Despite many studies emphasizing the prognostic value of the combination of renal and liver function on varied types of cardiac pathologies, [14][15][16][17][18][19][20] there is a paucity of data on TAVI.…”

“…Prior studies showed that TAVI can bring about improvements in renal function 6 but may also be complicated by kidney injury which is a risk factor for prognosis 7–9 . However, liver function is underappreciated, with a few studies focusing on liver function only in patients with pre‐existing liver diseases 10–13 . Despite many studies emphasizing the prognostic value of the combination of renal and liver function on varied types of cardiac pathologies, 14–20 there is a paucity of data on TAVI.…”