Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease

Abstract

Objectives: To examine whether transcatheter aortic valve replacement (TAVR) is a safe and effective treatment option for aortic stenosis in patients with end-stage renal disease (ESRD). Background: Patients with ESRD undergoing surgical aortic valve replacement have an operative mortality approaching 20% and a 10-year survival of approximately 12%. We investigated whether TAVR is a more reasonable option. Methods: This is a multicenter, retrospective study of all patients with ESRD who underwent TAVR in 8 institutions between 12/2011 and 02/2013. Demographic characteristics, mortality, major, and minor complications were evaluated. Outcomes were stratified by operative approach. Results: Forty-three patients with a mean age 76.2 6 11.0 years and a mean STS predicted risk of mortality of 15.53 6 8.70% underwent TAVR. Mean duration of dialysis was 45.2 6 52.3 months (median 29.5 months). Transfemoral (TF) TAVR was performed in 31/43 (72.1%), transapical in 11/43 (25.6%), and transaortic in 1/ 43 (2.3%). Operative mortality was 14.0% (6/43) with TF mortality 6.5% (2/31) and 33.3% (4/12) in non-TF patients. Six-month mortality was 11/43 (25.6%: 16.1% TF, 50.0% non-TF). Complications included stroke in 2.3% (1/43) and life-threatening or major bleeding in 14.0% (6/43). Discharge to another healthcare facility was 27.0% (10/37). Readmission within 30 days of procedure for any cause was 18.9% (7/37). Conclusions: Patients with ESRD who undergo TAVR are at high risk for mortality and complications. TAVR outcomes are comparable to but not substantially better than those with SAVR. Transfemoral TAVR seems to be at least as safe and effective as the current standard SAVR in patients undergoing aortic valve replacement. V C 2016 Wiley Periodicals, Inc.

Chronic kidney disease and valvular heart disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…Likewise, patients undergoing dialysis had a higher 1-year mortality (37% vs. 19%; P < 0.01) and a higher rate of major bleeding (1.4% vs. 1.0%; P ¼ 0.03) in 3053 (4.2%) of >72,000 patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies registry. 73 Analogous findings were identified in another group of dialysis patients undergoing TAVR, who had a 1-year mortality rate of 39%, compared with a 17.5% rate in those with CKD G3a (eGFR between 45-59 ml/min per 1.73 m 2 ). 65 This mortality rate appears to be further amplified by the presence of atrial fibrillation, with 1-year mortality rates as high as 71%.…”

Aortic Stenosis Patients With Transcatheter Aortic Valve Replacement: Caution Recommended With Renal Failure During Hospitalization

“…One of the studies showed that most patients with ESRD have numerous comorbidities along with experiencing effects of advanced AS and prognosis of ESRD patients is highly affected by the presence of other comorbidities and their functional status. Comorbidities like peripheral vascular disease, coronary artery disease, CHF, and diabetes are associated with nearly 50% one-year survival in elderly patients on dialysis [4]. Another meta-analysis suggested that the occurrence of RF requiring hemodialysis following TAVR is related to baseline comorbidities instead of the amount of contrast used [12].…”

“…Most patients with ESRD have numerous comorbidities along with experiencing the effects of advanced AS. The prognosis of ESRD patients is affected by the presence of comorbidities like peripheral vascular disease, CAD, congestive heart failure (CHF), diabetes, and chronic pulmonary disease with nearly 50% one-year survival in elderly patients on dialysis [4].…”

“…Individuals with ESRD and AKI have increased in-hospital mortality, increased occurrence of in-hospital complications, and poor outcomes following TAVR [7]. Individuals with advanced AS and ESRD undergoing TAVR have a remarkably elevated risk of mortality at 30 days and one-year and increased in-hospital mortality compared to non-dialysis patients [4].…”

A 91-year-old woman with severe aortic stenosis successfully underwent maintenance hemodialysis via arteriovenous fistula after transcatheter aortic valve implantation: a case report with literature review

“…Unfortunately, there is no information as to whether patients underwent HD via an AVF/ arteriovenous graft, a tunneled central catheter or arterial superficialization in the studies. The mortality rates in the short-term (30 days/1 year) and long-term (2 years/3 years) periods after TAVI are 0 to 15.2%/0 to 45.2% and 53%/73.2%, respectively [5,15,23,[25][26][27][28][29]. At present, the Japanese healthcare system does not reimburse TAVI for dialysis patients.…”