Clinical impact of baseline chronic kidney disease in patients undergoing transcatheter or surgical aortic valve replacement

Abstract

Objectives To assess the treatment effect of TAVR versus SAVR on clinical outcomes to 3 years in patients stratified by chronic kidney disease (CKD) by retrospectively studying patients randomized to TAVR or SAVR. Background The impact of CKD on mid‐term outcomes of patients undergoing TAVR versus SAVR is unclear. Methods Patients randomized to TAVR or SAVR in the CoreValve US Pivotal High Risk Trial were retrospectively stratified by eGFR: none/mild or moderate/severe CKD. To evaluate the impact of baseline CKD in TAVR patients only, all patients undergoing an attempted TAVR implant in the US Pivotal Trial and CAS were stratified by baseline eGFR into none/mild, moderate, and severe CKD. The primary endpoint was major adverse cardiovascular and renal events (MACRE), a composite of all‐cause mortality, myocardial infarction, stroke/TIA, and new requirement of dialysis. Results Moderate/severe CKD was present in 62.7% and 60.7% of high‐risk patients randomized to TAVR or SAVR, respectively. Baseline characteristics were similar between TAVR and SAVR patients in both CKD subgroups, except for higher rates of diabetes and higher serum creatinine in SAVR patients. Among high‐risk patients with moderate/severe CKD, TAVR provided a lower 3‐year MACRE rate compared with SAVR: 42.1% vs. 51.0, P = .04. Of 3,733 extreme‐ and high‐risk TAVR patients, 39.9% had none/mild, 53.8% moderate, and 6.4% severe CKD. Worsening baseline CKD was associated with increased 3‐year MACRE rates [none/mild 51.5%, moderate 54.5%, severe 63.1%, P = .001]. Conclusions TAVR results in lower 3‐year MACRE versus SAVR in high‐risk patients with moderate/severe CKD. In patients undergoing TAVR, worsening CKD increases mid‐term mortality and MACRE. Randomized trials of TAVR vs. SAVR in patients with moderate‐severe CKD would help elucidate the best treatment for these complex patients. Trial Registration CoreValve US Pivotal Trial: NCT01240902. CoreValve Continued Access Study: NCT01531374.

Impact of bleeding after transcatheter aortic valve replacement in patients with chronic kidney disease

“…Third, while there were no differences in discharge antithrombotic therapies, patients with CKD had a higher risk of bleeding following TAVR on DAPT compared to patients without CKD. Previous reports suggest that the risk for mortality at 1 year for patients with CKD undergoing TAVR ranges from 14 to 25%, which is consistent with what is reported in the present study 5,13‐15 . Similarly, the rate of ischemic stroke following TAVR is in line with prior systematic review of 1 to 11% with a median of 4% 16 …”

Transcatheter versus surgical aortic valve replacement in aortic stenosis patients with advanced chronic kidney disease: a systematic review and meta-analysis

“…After a strict appraisal, 21 studies including 12 propensity score-matched, 8 observational cohort studies, and 1 randomized controlled study were included. Except for 10 studies included in the previous meta-analysis, 2 missed studies and 9 recently published studies were included, 38,989 patients with advanced CKD were incorporated into the data synthesis (16,(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40).…”

Table_1.DOCX

“…Despite propensity score matching, younger AF patients who underwent TAVR were likely to have more comorbidity and are frailer, and surgeons were reluctant or refuse to offer SAVR, which may account for the increased mortality in the younger group. Consistent with prior studies (20,21), the benefit of TAVR regarding the reduction in acute kidney injury occurs across all subgroups, although it is more evident in patients comorbid with CKD and congestive heart failure.…”