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

Transcatheter aortic valve implantation versus surgical aortic valve replacement in chronic kidney disease: Meta-analysis of reconstructed time-to-event data

BACKGROUND

Patients with advanced chronic kidney disease (CKD) are a challenging and understudied population. Specifically, the late outcomes following surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) in patients with CKD remains uncertain.

OBJECTIVES

To compare overall mortality risk in patients with moderate-to-severe CKD following TAVI versus SAVR.

METHODS

Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by August 2022.

RESULTS

Nine studies met our inclusion criteria. Patients who underwent TAVI had a higher 5-year mortality compared with patients undergoing SAVR in the overall population (HR 1.56, 95% CI 1.44-1.69, P < 0.001) and in populations with similar risk scores (HR 1.15, 95% CI 1.01-1.31, P = 0.035). The landmark analysis revealed a lower risk of 30-day mortality with TAVI (HR 0.62, 95% CI 0.41-0.94, P = 0.023), followed by similar risk until 7.5 months (HR 1, 95% CI 0.78-1.27, P = 0.978). In contrast, the landmark analysis beyond 7.5 months yielded a reversal of the HR in favor of SAVR (TAVI with HR 1.27, 95% CI 1.08-1.49 P = 0.003).

CONCLUSIONS

In patients with CKD, TAVI provides an initial survival benefit over SAVR. However, in the long run, a significant survival benefit of SAVR over TAVI was observed. Our findings highlight the need for randomized controlled trials to investigate outcomes in this special population.

Cardiovascular Outcomes of Transcatheter Aortic Valve Implantation in Patients With Chronic Kidney Disease in Octogenarian Population

Limited data are available regarding in-hospital outcomes of transcatheter aortic valve implantation (TAVI) in the octogenarian population with chronic kidney disease (CKD). We sought to study the cardiovascular outcomes of TAVI in CKD hospitalization with different stages at the national cohort registry. We used the National Inpatient Sample database to compare TAVI CKD low-grade (LG) (stage I to IIIa, b) versus TAVI CKD high-grade (HG) (stage IV to V) in octogenarians. Outcomes such as inpatient mortality, cardiogenic shock, new permanent pacemaker implantation, acute kidney injury), sudden cardiac arrest, mechanical circulatory support, major bleeding, transfusion, and resource utilization were compared between the 2 cohorts. A total of 74,766 octogenarian patients (TAVI CKD-HG n = 12,220; TAVI CKD-LG n = 62,545) were included in our study. On matched analysis, TAVI CKD-HG had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.0-2.5, p <0.0001), cardiogenic shock (aOR 1.22, 95% CI 1.07 to 1.39, p = 0.0019), permanent pacemaker implantation (aOR 1.14, 95% CI 1.06 to 1.23, p = 0.0006), acute kidney injury (aOR 1.19, 95% CI 1.13 to 1.27, p <0.0001), sudden cardiac arrest (aOR 1.32, 95% CI 1.09 to 1.61, p = 0.004), major bleeding (aOR 1.1, 95% CI 1.006 to 1.22, p <0.0368) and higher rates of blood transfusion (aOR 1.62, 95% CI 1.5 to 1.75, p <0.0001) when compared with the TAVI CKD-LG cohort. However, there was no statistically significant difference in the odds of cerebrovascular accident and mechanical circulatory support use between the 2 groups.

In-hospital outcomes of transcatheter aortic valve replacement in patients with chronic and end-stage renal disease: a nationwide database study

BACKGROUND

Chronic kidney disease (CKD) and end-stage renal disease (ESRD) have been associated with worse outcomes after transcatheter aortic valve replacement (TAVR). With TAVR indications extending to a wider range of patient populations, it is important to understand the current implications of chronic renal insufficiency on clinical outcomes. We aim to determine the impact of CKD and ESRD on in-hospital outcomes after TAVR.

METHODS

We queried the National Inpatient Sample for TAVR performed between 2016 and 2020 using International Classification of Diseases-10th Revision codes. We compared in-hospital mortality and clinical outcomes between three groups: normal renal function, CKD and ESRD. The association between CKD/ESRD and outcomes was tested with multivariable logistic regression analyses, using normal renal function as baseline.

RESULTS

In the five-year study period, 279,195 patients underwent TAVR (mean age 78.9 ± 8.5 years, 44.4% female). Of all patients, 67.1% had normal renal function, 29.2% had CKD, and 3.7% had ESRD. There were significant differences in age, sex, and prevalence of comorbidities across groups. In-hospital mortality was 1.3%. Compared to patients with normal renal function, patients with renal insufficiency had higher in-hospital mortality, with the highest risk found in patients with ESRD (adjusted odds ratio: 1.4 [95% confidence interval: 1.2-1.7] for CKD; adjusted odds ratio: 2.4 [95% confidence interval: 1.8-3.3] for ESRD). Patients with CKD or ESRD had a higher risk of cardiogenic shock, need for mechanical circulatory support, and vascular access complications, compared to those with normal renal function. In addition, patients with ESRD had a higher risk of cardiac arrest and periprocedural acute myocardial infarction. The incidence of conversion to open heart surgery was 0.3% and did not differ between groups. Post-procedural infectious and respiratory complications were more common among patients with CKD or ESRD.

CONCLUSION

Patients with CKD and ESRD are at higher risk of in-hospital mortality, cardiovascular, and non-cardiovascular complications after TAVR. The risk of complications is highest in patients with ESRD and does not result in more frequent conversion to open heart surgery. These results emphasize the importance of individualized patient selection for TAVR and procedural planning among patients with chronic renal insufficiency.

Impact of reintervention after index aortic valve replacement on the risk of subsequent mortality

Objectives

The use of bioprosthetic aortic valve replacement (AVR) is inherently associated with a risk of structural valve degeneration (SVD) and the need for aortic valve (AV) reintervention. We sought to evaluate whether AV reintervention, in the form of repeat surgical AVR (SAVR) or valve-in-valve transcatheter aortic valve replacement (ViV-TAVR), negatively affects patients' subsequent long-term survival after index SAVR.

Methods

We identified patients who had undergone bioprosthetic SAVR from 2002 to 2017 at our institution. Median longitudinal follow-up after index SAVR was 7.3 years (10.9 years for those with and 7.2 years for those without AV reintervention), and median follow-up after AV reintervention was 1.9 years. Cox regression analyses using AV reintervention (re-SAVR and ViV-TAVR) as a time-varying covariate were used to determine the impact of reintervention on subsequent survival.

Results

Of 4167 patients who underwent index SAVR, 139 (3.3%) required AV reintervention for SVD, with re-SAVR being performed in 65 and ViV-TAVR in 74. Median age at the index SAVR was 73 years (interquartile range, 64-79 years), and 2541 (61%) were male. Overall, there were total of 1171 mortalities observed, of which 13 occurred after re-SAVR and 9 after ViV-TAVR. AV reintervention was associated with a greater risk of subsequent mortality compared with those patients who did not require AV reintervention (hazard ratio, 2.53; 95% confidence interval, 1.64-3.88, P < .001). This increased risk of subsequent mortality was more pronounced for those who received their index AVR when <65 years of age (hazard ratio, 5.60; 95% confidence interval, 2.57-12.22, P < .001) versus those ≥65 years (2.06, 1.21-3.52, P = .008). Direct comparison of survival between those who underwent re-SAVR versus ViV-TAVR showed 5-year survival to be comparable (re-SAVR: 74% vs ViV-TAVR: 80%, P = .67).

Conclusions

Among patients receiving bioprosthetic AVR, an AV reintervention for SVD is associated with an increased risk of subsequent mortality, regardless of re-SAVR or ViV-TAVR, and this risk is greater among younger patients. These findings should be balanced with individual preferences at index AVR in the context of patients' lifetime management of aortic stenosis.

Aortic Stenosis and Aortic Valve Replacement among Patients with Chronic Kidney Disease: A Narrative Review

BACKGROUND

Aortic stenosis (AS) can present with dyspnea, angina, syncope, and palpitations, and this presents a diagnostic challenge as chronic kidney disease (CKD) and other commonly found comorbid conditions may present similarly. While medical optimization is an important aspect in management, aortic valve replacement (AVR) by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) is the definitive treatment. Patients with concomitant CKD and AS require special consideration as it is known that CKD is associated with progression of AS and poor long-term outcomes.

AIMS AND OBJECTIVES

The aim of the study was to summarize and review the current existing literature on patients with both CKD and AS regarding disease progression, dialysis methods, surgical intervention, and postoperative outcomes.

CONCLUSION

The incidence of AS increases with age but has also been independently associated with CKD and furthermore with hemodialysis (HD). Regular dialysis with HD versus peritoneal dialysis (PD) and female gender have been associated with progression of AS. Management of AS is multidisciplinary and requires planning and interventions by the heart-kidney team to decrease the risk of further inducing kidney injury among high-risk population. Both TAVR and SAVR are effective interventions for patients with severe symptomatic AS, but TAVR has been associated with better short-term renal and cardiovascular outcomes.

IMPLICATIONS FOR PRACTICE

Special consideration must be given to patients with both CKD and AS. The choice of whether to undergo HD versus PD among patients with CKD is multifactorial, but studies have shown benefit regarding AS progression among those who undergo PD. The choice regarding AVR approach is likewise the same. TAVR has been associated with decreased complications among CKD patients, but the decision is multifactorial and requires a comprehensive discussion with the heart-kidney team as many other factors play a role in the decision including preference, prognosis, and other risk factors.

Impact of cystatin C-derived glomerular filtration rate in patients undergoing transcatheter aortic valve implantation

Background

Chronic kidney disease (CKD) impacts prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). While estimated glomerular filtration rate (eGFR) calculated from serum creatinine [eGFR (creatinine)] is affected by body muscle mass which reflects frailty, eGFR calculated from serum cystatin C [eGFR (cystatin C)] is independent of body composition, resulting in better renal function assessment.

Methods

This study included 390 consecutive patients with symptomatic severe aortic stenosis (AS) who underwent TAVI, and measured cystatin C-based eGFR at discharge. Patients were divided into two groups, with or without CKD estimated with eGFR (cystatin C). The primary endpoint of this study was the 3-year all-cause mortality after TAVI.

Results

The median patient age was 84 years, and 32.8% patients were men. Multivariate Cox regression analysis indicated that eGFR (cystatin C), diabetes mellitus, and liver disease were independently associated with 3-year all-cause mortality. In the receiver-operating characteristic (ROC) curve, the predictive value of eGFR (cystatin C) was significantly higher than that of eGFR (creatinine). Furthermore, Kaplan-Meier estimates revealed that 3-year all-cause mortality was higher in the CKD (cystatin C) group than that in the non-CKD (cystatin C) group with log-rank p = 0.009. In contrast, there was no significant difference between the CKD (creatinine) and non-CKD (creatinine) groups with log-rank p = 0.94.

Conclusions

eGFR (cystatin C) was associated with 3-year all-cause mortality in patients who underwent TAVI, and it was superior to eGFR (creatinine) as a prognostic biomarker.

End-stage renal disease, calcification patterns and clinical outcomes after TAVI

BACKGROUND

Patients with chronic hemodialysis due to end-stage renal disease (ESRD) or severely impaired kidney function (CKD) constitute a relevant share of patients undergoing trans-catheter aortic valve implantation (TAVI). However, data on specific challenges and outcomes remain limited.

AIM

We aimed to characterize this patient population, evaluate clinical results and assess the significance of calcification patterns.

METHODS

This retrospective single-center analysis evaluated 2,712 TAVI procedures (2012-2019) according to baseline renal function: GFR < 30 ml/min/1.73m2 (CKD; n = 210), chronic hemodialysis (ESRD; n = 119) and control (CTRL; n = 2383). Valvular and vascular calcification patterns were assessed from contrast-enhanced multi-detector computed tomography. Outcomes were evaluated in accordance with the VARC-2 definitions.

RESULTS

Operative risk was higher in ESRD and CKD vs. CTRL (STS-score 8.4% and 7.6% vs. 3.9%, p < 0.001) and patients with ESRD had more severe vascular calcifications (49.1% vs. 33.9% and 29.0%, p < 0.01). Immediate procedural results were similar but non-procedure-related major/life-threatening bleeding was higher in ESRD and CKD (5.0% and 5.3% vs. 1.6%, p < 0.01). 3-year survival was impaired in patients with ESRD and CKD (33.3% and 35.3% vs. 65.4%, p < 0.001). Multivariable analysis identified ESRD (HR 1.60), CKD (HR 1.79) and vascular calcifications (HR 1.29) as predictors for 3-year and vascular calcifications (HR 1.51) for 30-day mortality.

CONCLUSION

Patients with ESRD and CKD constitute a vulnerable patient group with extensive vascular calcifications. Immediate procedural results were largely unaffected by renal impairment, yielding TAVI a particularly valuable treatment option in these high-risk operative patients. Mid-term survival was determined by underlying renal disease, cardiovascular comorbidities, and vascular calcifications as a novel risk marker.

Propensity matched comparison of TAVI and SAVR in intermediate-risk patients with severe aortic stenosis and moderate-to-severe chronic kidney disease: a subgroup analysis from the German Aortic Valve Registry

OBJECTIVE

We compared TAVI vs. SAVR in patients with moderate-to-severe chronic kidney disease (eGFR 15-60 ml/min/1.73 m2) for whom both procedures could possibly be considered (age ≤ 80 years, STS-score 4-8).

BACKGROUND

According to both ACC/AHA and ESC/EACTS recent guidelines, aortic stenosis may be treated with either transcatheter (TAVI) or surgical (SAVR) aortic valve replacement in a subgroup of patients. A shared therapeutic decision is made by a heart team based on individual factors, including chronic kidney disease (CKD).

METHODS

Data from the large nationwide German Aortic Valve Registry were used. A propensity score method was used to select 704 TAVI and 374 SAVR matched patients. Primary endpoint was 1-year survival. Secondary endpoints were clinical complications, including pacemaker implantation, vascular complications, myocardial infarction, bleeding, and the need for new-onset dialysis.

RESULTS

One-year survival was similar (HR [95% CI] for TAVI 1.271 [0.795, 2.031], p = 0.316), with no divergence in Kaplan-Meier curves. In spite of post-procedural short-term survival being numerically higher for TAVI patients and 1-year survival being numerically higher for SAVR patients, such differences did not reach statistical significance (96.4% vs. 94.2%, p = 0.199, and 86.2% vs. 81.2%, p = 0.316, respectively). In weighted analyses, pacemaker implantation, vascular complications, and were significantly more common with TAVI; whereas myocardial infarction, bleeding requiring transfusion, and longer ICU-stay and overall hospitalization were higher with SAVR. Temporary dialysis was more common with SAVR (p < 0.0001); however, a probable need for chronic dialysis was rare and similar in both groups.

CONCLUSION

Both TAVI and SAVR led to comparable and excellent results in patients with moderate-to-severe CKD in an intermediate-risk population of patients with symptomatic severe aortic stenosis for whom both therapies could possibly be considered.

Management of Patients With Kidney Disease in Need of Cardiovascular Catheterization: A Scientific Workshop Cosponsored by the National Kidney Foundation and the Society for Cardiovascular Angiography and Interventions

Patients with chronic kidney disease (CKD) are at an increased risk of developing cardiovascular disease (CVD), whereas those with established CVD are at risk of incident or progressive CKD. Compared with individuals with normal or near normal kidney function, there are fewer data to guide the management of patients with CVD and CKD. As a joint effort between the National Kidney Foundation and the Society for Cardiovascular Angiography and Interventions, a workshop and subsequent review of the published literature was held. The present document summarizes the best practice recommendations of the working group and highlights areas for further investigation.

Valvular Heart Disease in Patients with Chronic Kidney Disease

Valvular heart disease (VHD) is highly prevalent in patients with chronic kidney disease (CKD) from the early stages to end-stage renal disease (ESRD). Aortic and mitral valves are the most frequently affected, leading to aortic valve and/or mitral annular calcification, which, in turn, causes either valve stenosis or regurgitation at an accelerated rate compared with the general population. Tricuspid regurgitation is also prevalent in CKD and ESRD, and haemodialysis patients are at an increasingly high risk of infective endocarditis. As for pathophysiology, several mechanisms causing VHD in CKD have been proposed, highlighting the complexity of the process. Echocardiography constitutes the gold standard for the assessment of VHD in CKD/ESRD patients, despite the progress of other imaging modalities. With regard to treatment, the existing 2017 European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on the management of VHD addressing patients with normal kidney function are also applied to patients with CKD/ESRD.

Impact of Chronic Kidney Disease on the Prognosis of Transcatheter Aortic Valve Replacement in Patients with Aortic Stenosis: a Meta-Analysis of 133624 Patients

Purpose: The impact of chronic kidney disease (CKD) on the prognosis of transcatheter aortic valve replacement (TAVR) remains unclear. The purpose of this meta-analysis was to assess the impact of CKD and different stages of CKD on prognosis in patients undergoing TAVR.

Methods: As of June 2020, we performed a comprehensive literature search on relevant studies using PubMed, Embase, Cochrane Library, and Web of Science. Subsequently, we pooled the risk ratio (RR) of individual studies via random effects to analyze heterogeneity, quality assessment, and publication bias.

Results: A total of 20 studies, involving 133624 patients, were eligible for analysis. Patients with CKD had higher all-cause mortality at 30 days (RR: 1.39, 95% confidence interval [CI]: 1.31–1.47, P <0.001), 1 year (RR: 1.36, 95% CI: 1.24–1.49, P <0.001), and 2 years (RR: 1.2, 95% CI: 1.05–1.38, P = 0.009) of follow-up. Moreover, they also had higher acute kidney injury (AKI) (RR: 1.38, 95% CI: 1.16–1.63, P <0.001) and bleeding (RR: 1.33, 95% CI: 1.18–1.50, P <0.001) at 30 days. CKD3 alone also increased all-cause mortality at follow-ups. Risk of all-cause mortality increased with severity of CKD for stages 3, 4, and 5 at follow-up.

Conclusion: Patients with CKD are at an increased risk of all-cause mortality, AKI, and bleeding events after TAVR. Moreover, the mortality risk rises with increasing severity of CKD.

Predictors and clinical outcomes of poor symptomatic improvement after transcatheter aortic valve replacement

Objective

Transcatheter aortic valve replacement (TAVR) improves clinical symptoms in most patients with severe aortic stenosis (AS). However, some patients do not benefit from the symptom-reducing effects of TAVR. We assessed the predictors and clinical outcomes of poor symptomatic improvement (SI) after TAVR.

Methods

A total of 1749 patients with severe symptomatic AS undergoing transfemoral TAVR were evaluated using the Japanese multicentre TAVR registry. Poor SI was defined as readmission for heart failure (HF) within 1 year after TAVR or New York Heart Association (NYHA) class ≥3 after 1 year. A logistic regression model was used to identify predictors of poor SI. One-year landmark analysis after TAVR was used to evaluate the association between poor SI and clinical outcomes.

Results

Among the overall population (mean age, 84.5 years; female, 71.3%; mean STS score, 6.3%), 6.6% were categorised as having poor SI. Atrial fibrillation, chronic obstructive pulmonary disease, Clinical Frailty Scale ≥4, chronic kidney disease and moderate to severe mitral regurgitation were independent predictors of poor SI. One-year landmark analysis demonstrated that poor SI had a higher incidence of all-cause death and readmission for HF compared with SI (p<0.001). Poor SI with preprocedural NYHA class 2 had a worse outcome than SI with preprocedural NYHA class ≥3.

Conclusions

Poor SI was associated with worse outcomes 1 year after the procedure. It had a greater impact on clinical outcomes than baseline symptoms. TAVR may be challenging for patients with many predictors of poor SI.

Trial registration number

This registry, associated with the University Hospital Medical Information Network Clinical Trials Registry, was accepted by the International Committee of Medical Journal Editors (UMIN-ID: 000020423).

5-Year Outcomes Comparing Surgical Versus Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease

OBJECTIVES

The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

BACKGROUND

Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset.

METHODS

Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m²) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed.

RESULTS

The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR.

CONCLUSIONS

In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.

Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association

Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.

Clinical outcomes of renal and liver transplant patients undergoing transcatheter aortic valve replacement: analysis of national inpatient sample database

Background: The transcatheter aortic valve replacement (TAVR) has recently gained traction as a viable alternative to surgical aortic valve replacement (SAVR), but data on its safety and clinical outcomes in transplant patients are limited.Methods: We retrieved relevant demographic and clinical outcome data from the U.S. National Inpatient Sample (NIS) for the year 2012-2015. The clinical outcomes of TAVR in renal transplant (RT) and liver transplant (LT) were ascertained using an adjusted odds ratio (aOR) with a 95% confidence interval (CI) on Mantzel-Hensel test.Results: A total of 62,399 TAVR patients were identified; 62,180 (99.6%) with no history of transplant, 219 (0.4%) with RT and 85 (0.1%) with LT. There was no significant difference in odds of in-hospital mortality (OR 0.61, 95% CI 0.25-1.5, p = 0.37), major cardiovascular, respiratory or neurological complications in patients with and without RT. Similarly, the odds of cardiac complications, renal and neurological complications between patients with and without LT were identical.Conclusion: Compared to non-transplant patients, TAVR appears to be associated with similar odds of major systemic complications or mortality in patients with a history of kidney or liver transplant.

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement

OBJECTIVES

Chronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR).

METHODS

Patients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2, n = 421); Group 2 (eGFR = 30-59 ml/min/1.73 m2, n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m2, n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity.

RESULTS

Severe CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan-Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99).

CONCLUSIONS

Higher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.

Temporal Trends and Outcomes of Percutaneous and Surgical Aortic Valve Replacement in Patients With Atrial Fibrillation

Objectives: The aim of this study was to evaluate the temporal trends of transcatheter aortic valve replacement (TAVR) in severe aortic stenosis (AS) patients with atrial fibrillation (AF) and to compare the in-hospital outcomes between TAVR and surgical aortic valve replacement (SAVR) in patients with AF.

Background: Data comparing TAVR to SAVR in severe AS patients with AF are lacking.

Methods: National inpatient sample database in the United States from 2012 to 2016 were queried to identify hospitalizations for severe aortic stenosis patients with AF who underwent isolated aortic valve replacement. A propensity score-matched analysis was used to compare in-hospital outcomes for TAVR vs. SAVR for AS patients with AF.

Results: The analysis included 278,455 hospitalizations, of which 124,910 (44.9%) were comorbid with AF. Before matching, TAVR had higher in-hospital mortality than SAVR (3.1 vs. 2.2%, p < 0.001); however, there was a declining trend during the study period (Ptrend < 0.001). After matching, TAVR and SAVR had similar in-hospital mortality (2.9 vs. 2.9%, p < 0.001) and stroke. TAVR was associated with lower rates of acute kidney injury, new dialysis, cardiac complications, acquired pneumonia, sepsis, mechanical ventilation, tracheostomy, non-routine discharge, and shorter length of stay; however, TAVR was associated with more pacemaker implantation and higher cost. Of the patients receiving TAVR, the presence of AF was associated with an increased rate of complications and increased medical resource usage compared to those without AF.

Conclusions: In-hospital mortality and stroke for TAVR and SAVR in AF, AS are similar; however, the in-hospital mortality in TAVR AF is declining and associated with more favorable in-hospital outcomes.

Risk of mortality following transcatheter aortic valve replacement for low-flow low-gradient aortic stenosis

BACKGROUND

Low-flow low-gradient (LF-LG) aortic stenosis (AS) is associated with high mortality, even after transcatheter aortic valve replacement (TAVR). Further knowledge of risk indicators is needed and a clinical risk score would be desirable for optimizing patient selection and therapeutic strategy.

METHODS

The study cohort comprised of 219 consecutive LF-LG AS patients undergoing TAVR from 2008 to 2018 in two high-volume German centers. Predictive factors for one-year all-cause mortality were defined according to a Cox proportional hazard model.

RESULTS

At one-year follow-up after TAVR, 28% of patients had died. A multivariate model revealed six independent predictors of one-year mortality: history of myocardial infarction (HR 2.05, 95%CI 1.13-3.72), eGFR < 30 ml/min/1.73m² (HR 2.75, 95%CI 1.48-5.11), tricuspid regurgitation moderate or more (HR 2.06, 95%CI 1.14-3.72), stroke volume index < 25 mL/m² (HR 2.03, 95%CI 1.14-3.62), self-expandable device (HR 2.72, 95%CI 1.17-6.27), and non-transfemoral approach (HR 3.42, 95%CI 1.28-9.14). The Rhineland Risk Score (RRS) consisting of these variables (c statistic 0.75, 95%CI 0.68-0.82, p < 0.001) was superior to the EuroSCORE II (c statistic 0.63) and STS-PROM score (c statistic 0.69) at predicting one-year mortality. Patients with a RRS ≥ 8 had a prohibitive risk of one-year mortality of 67.6% (95%CI 52.0-82.4%).

CONCLUSION

In patients with LF-LG AS, history of myocardial infarction, renal dysfunction, tricuspid regurgitation, a low stroke volume index, self-expandable device, and non-femoral approach were associated with increased 1-year mortality after TAVR. The RRS might serve as a helpful tool for risk prediction and patient selection for TAVR in patients with LF-LG AS.

Transcatheter and surgical aortic valve replacement impact on outcomes and cancer treatment schedule

BACKGROUND

Recent data suggest that transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic stenosis (AS) is viable in cancer patients. TAVR may be preferred in cancer patients due to its minimally invasive nature and smaller impact on oncologic therapies compared to SAVR. Objectives We sought to determine if TAVR is an acceptable alternative to SAVR in cancer patients and whether TAVR allows for earlier initiation or resumption of anti-cancer therapies.

METHODS

Cancer patients in a tertiary cancer center diagnosed with severe AS were retrospectively included. Patients accepted by the heart team underwent either TAVR or SAVR, while remaining patients received medical therapy alone. Time intervals to initiation of cancer treatment and the impact of cancer treatment on the replaced valves were recorded. Logistic regression was performed to determine the impact of treatment strategy on overall survival (OS) in all 3 subgroups.

RESULTS

One hundred and eighty-seven cancer patients diagnosed with severe AS were identified. AVR was associated with better OS compared to medical therapy alone (p < 0.0001). TAVR was associated with better OS at 72 months (HR = 0.468, p < 0.001) compared to medical therapy alone, with no difference in OS observed between SAVR and TAVR. Time intervals to initiation of cancer treatments were shorter in the TAVR group, with no valve deterioration or infection observed in all groups.

CONCLUSION

Cancer patients with severe AS benefit from AVR. TAVR is a viable alternative to SAVR in high-risk cancer patients to prolong survival and allow for earlier administration or resumption of anti-neoplastic therapies.

Women with chronic kidney disease undergoing transcatheter aortic valve replacement: Caveat emptor

Over 60% of women presenting for transcatheter aortic valve replacement (TAVR) have coexisting chronic kidney disease (CKD). In women undergoing TAVR, CKD was associated with significantly higher rates of adverse events, including a twofold higher rate of risk-adjusted mortality at 1 year. This study is an important step forward in our understanding of risk stratification in women with CKD undergoing TAVR and suggests that measures to optimize outcomes warrant further investigation in this high-risk group of patients.

Transcatheter aortic valve replacement: Protect the kidneys to protect the patient

Transcatheter aortic valve replacement (TAVR) seems superior to surgical aortic valve replacement (SAVR) for intermediate-term outcomes in patients with aortic stenosis and moderate to severe chronic kidney disease (CKD). Intermediate-term mortality and the major adverse cardiac and renal event increase if the renal function worsens soon after TAVR or SAVR. Patient's demographic profile, comorbid conditions, and procedural characteristics influence the clinical outcomes emphasizing the need for careful risk assessment in deciding TAVR versus SAVR in CKD patient.