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Khawaja M, Virk HUH, Bandyopadhyay D, Rodriguez M, Escobar J, Alam M, Jneid H, Krittanawong C. Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation. J Cardiovasc Dev Dis 2023; 10:265. [PMID: 37504521 PMCID: PMC10380398 DOI: 10.3390/jcdd10070265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 07/29/2023] Open
Abstract
Patients with a clinical indication for aortic valve replacement can either undergo surgical aortic valve replacement (SAVR) or Transcatheter Aortic Valve Implantation (TAVI). There are many different factors that go into determining which type of replacement to undergo, including age, life expectancy, comorbidities, frailty, and patient preference. While both options offer significant benefits to patients in terms of clinical outcomes and quality of life, there is growing interest in expanding the indications for TAVI due to its minimally invasive approach. However, it is worth noting that there are several discrepancies in TAVI outcomes in regards to various endpoints, including death, stroke, and major cardiovascular events. It is unclear why these discrepancies exist, but potential explanations include the diversity of etiologies for aortic stenosis, complex patient comorbidities, and ongoing advancements in both medical therapies and devices. Of these possibilities, we propose that phenotypic variation of aortic stenosis has the most significant impact on post-TAVI clinical outcomes. Such variability in phenotypes is often due to a complex interplay between underlying comorbidities and environmental and inherent patient risk factors. However, there is growing evidence to suggest that patient genetics may also play a role in aortic stenosis pathology. As such, we propose that the selection and management of TAVI patients should emphasize a precision medicine approach.
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Affiliation(s)
- Muzamil Khawaja
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Dhrubajyoti Bandyopadhyay
- Department of Cardiology, Westchester Medical Centre, New York Medical College, Valhalla, NY 10595, USA
| | - Mario Rodriguez
- Division of Cardiology, Barnes-Jewish Hospital at Washington University in St. Louis School of Medicine, Saint Louis, MO 63110, USA
| | - Johao Escobar
- Division of Cardiology, Harlem Cardiology, New York, NY 10035, USA
| | - Mahboob Alam
- Division of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX 77030, USA
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77030, USA
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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Park DY, An S, Hanna JM, Wang SY, Cruz-Solbes AS, Kochar A, Lowenstern AM, Forrest JK, Ahmad Y, Cleman M, Damluji AA, Nanna MG. Readmission rates and risk factors for readmission after transcatheter aortic valve replacement in patients with end-stage renal disease. PLoS One 2022; 17:e0276394. [PMID: 36264931 PMCID: PMC9584363 DOI: 10.1371/journal.pone.0276394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives We sought to examine readmission rates and predictors of hospital readmission following TAVR in patients with ESRD. Background End-stage renal disease (ESRD) is associated with poor outcomes following transcatheter aortic valve replacement (TAVR). Methods We assessed index hospitalizations for TAVR from the National Readmissions Database from 2017 to 2018 and used propensity scores to match those with and without ESRD. We compared 90-day readmission for any cause or cardiovascular cause. Length of stay (LOS), mortality, and cost were assessed for index hospitalizations and 90-day readmissions. Multivariable logistic regression was performed to identify predictors of 90-day readmission. Results We identified 49,172 index hospitalizations for TAVR, including 1,219 patients with ESRD (2.5%). Patient with ESRD had higher rates of all-cause readmission (34.4% vs. 19.2%, HR 1.96, 95% CI 1.68–2.30, p<0.001) and cardiovascular readmission (13.2% vs. 7.7%, HR 1.85, 95% CI 1.44–2.38, p<0.001) at 90 days. During index hospitalization, patients with ESRD had longer length of stay (mean difference 1.9 days), increased hospital cost (mean difference $42,915), and increased in-hospital mortality (2.6% vs. 0.9%). Among those readmitted within 90 days, patients with ESRD had longer LOS and increased hospital charge, but similar in-hospital mortality. Diabetes (OR 1.86, 95% CI 1.31–2.64) and chronic pulmonary disease (OR 1.51, 95% CI 1.04–2.18) were independently associated with higher odds of 90-day readmission in patients with ESRD. Conclusion Patients with ESRD undergoing TAVR have higher mortality and increased cost associated with their index hospitalization and are at increased risk of readmission within 90 days following TAVR.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois, United States of America
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Jonathan M. Hanna
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Stephen Y. Wang
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Ana S. Cruz-Solbes
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Ajar Kochar
- Section of Interventional Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Angela M. Lowenstern
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - John K. Forrest
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Michael Cleman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Abdulla Al Damluji
- Section of Interventional Cardiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- * E-mail:
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Kipourou K, O’Driscoll JM, Sharma R. Valvular Heart Disease in Patients with Chronic Kidney Disease. Eur Cardiol 2022; 17:e02. [PMID: 35154392 PMCID: PMC8819604 DOI: 10.15420/ecr.2021.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/19/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Konstantina Kipourou
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jamie M O’Driscoll
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK; School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, UK
| | - Rajan Sharma
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK; School of Psychology and Life Sciences, Canterbury Christ Church University, Canterbury, UK
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Ogami T, Kurlansky P, Takayama H, Ning Y, Ali ZA, Nazif TM, Vahl TP, Khalique O, Patel A, Hamid N, Ng VG, Hahn RT, Avgerinos DV, Leon MB, Kodali SK, George I. Long-Term Outcomes of Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease. J Am Heart Assoc 2021; 10:e019930. [PMID: 34387093 PMCID: PMC8475055 DOI: 10.1161/jaha.120.019930] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Aortic stenosis is prevalent in end‐stage renal disease. Transcatheter aortic valve replacement (TAVR) is a plausible alternative for surgical aortic valve replacement. However, little is known regarding long‐term outcomes in patients with end‐stage renal disease who undergo TAVR. Methods and Results We identified all patients with end‐stage renal disease who underwent TAVR from 2011 through 2016 using the United States Renal Data System. The primary end point was 5‐year mortality after TAVR. Factors associated with 1‐ and 5‐year mortality were analyzed. A total of 3883 TAVRs were performed for patients with end‐stage renal disease. Mortality was 5.8%, 43.7%, and 88.8% at 30 days, 1 year, and 5 years, respectively. Case volumes increased rapidly from 17 in 2011 to 1495 in 2016. Thirty‐day mortality demonstrated a dramatic reduction from 11.1% in 2012 to 2.5% in 2016 (P=0.01). Age 75 or older (hazard ratio [HR], 1.14; 95% CI, 1.05–1.23 [P=0.002]), body mass index <25 (HR, 1.18; 95% CI, 1.08–1.28 [P<0.001]), chronic obstructive pulmonary disease (HR, 1.25; 95% CI, 1.1–1.35 [P<0.001]), diabetes mellitus as the cause of dialysis (HR, 1.22; 95% CI, 1.11–1.35 [P<0.001]), hypertension as the cause of dialysis (HR, 1.17; 95% CI, 1.06–1.29 [P=0.004]), and White race (HR, 1.17; 95% CI, 1.06–1.3 [P=0.002]) were independently associated with 5‐year mortality. Conclusions Short‐term outcomes of TAVR in patients with end‐stage renal disease have improved significantly. However, long‐term mortality of patients on dialysis remains high.
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Affiliation(s)
- Takuya Ogami
- Department of Surgery New York-Presbyterian/Queens Flushing NY
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Yuming Ning
- Division of Cardiothoracic Surgery New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Ziad A Ali
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Tamim M Nazif
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Torsten P Vahl
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Omar Khalique
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Amisha Patel
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Nadira Hamid
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Vivian G Ng
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Rebecca T Hahn
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Dimitrios V Avgerinos
- Department of Cardiothoracic Surgery New York-PresbyterianWeill Cornell Medicine New York NY
| | - Martin B Leon
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Susheel K Kodali
- Division of Cardiology New York Presbyterian HospitalColumbia University Medical Center New York NY
| | - Isaac George
- Division of Cardiothoracic Surgery New York Presbyterian HospitalColumbia University Medical Center New York NY
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Mentias A, Desai MY, Saad M, Horwitz PA, Rossen JD, Panaich S, Jneid H, Kapadia S, Vaughan-Sarrazin M. Management of Aortic Stenosis in Patients With End-Stage Renal Disease on Hemodialysis. Circ Cardiovasc Interv 2020; 13:e009252. [PMID: 32772570 DOI: 10.1161/circinterventions.120.009252] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with end-stage renal disease on hemodialysis (ESRD-HD) and aortic stenosis have poor prognosis. The role of transcatheter aortic valve replacement (TAVR) in this high-risk population is debated. METHODS We compared the outcomes among ESRD-HD Medicare beneficiaries who were managed with TAVR, surgical AVR (SAVR), or conservative management for aortic stenosis between 2015 and 2017, using overlap propensity score weighting analysis to control for differences in treatment assignment. The primary outcome was all-cause mortality and was compared between treatment groups as well as to age-sex matched mortality for ESRD-HD in the US population. Secondary outcomes included trend of heart failure hospitalizations. RESULTS A total of 8107 ESRD-HD patients with aortic stenosis were included, 4130 (50%) underwent TAVR, 2565 (31.6%) underwent SAVR, and 1412 (17.4%) were managed conservatively. TAVR patients had more comorbidities and higher frailty compared with the other 2 groups. Thirty-day mortality was lower with TAVR compared with SAVR (4.6% versus 12.8%, P<0.01). After a median follow-up of 465 days (interquartile range, 261-759), on overlap propensity score weighting analysis, there was no difference in mortality between TAVR and SAVR (adjusted hazard ratio, 1.02 [95% CI, 0.91-1.15], P=0.7), and mortality was lower with TAVR compared with conservative management (adjusted hazard ratio, 0.53 [95% CI, 0.47-0.60], P<0.001). Standardized mortality ratios with TAVR, SAVR, and conservative management compared with age-sex matched ESRD-HD US population were 1.24, 1.27, and 1.83, respectively. The rate of heart failure admissions declined after TAVR (incidence rate ratio, 0.55 [95% CI, 0.48-0.62], P<0.001) and SAVR (incidence rate ratio, 0.76 [95% CI, 0.65-0.88], P<0.001). CONCLUSIONS In ESRD-HD patients with aortic stenosis, mortality was lower in the short-term with TAVR compared with SAVR but comparable in the mid-term. AVR is associated with an improvement in survival and reduction in heart failure hospitalizations compared with conservative management.
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Affiliation(s)
- Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.)
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH (M.Y.D., S.K.)
| | - Marwan Saad
- Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI (M.S.)
| | - Phillip A Horwitz
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.)
| | - James D Rossen
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.)
| | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.)
| | - Hani Jneid
- Division of Cardiology, Baylor College of Medicine, Houston, TX (H.J.)
| | - Samir Kapadia
- Heart and Vascular Institute, Cleveland Clinic Foundation, OH (M.Y.D., S.K.)
| | - Mary Vaughan-Sarrazin
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.).,Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center (M.V.-S.)
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Chronic kidney disease and valvular heart disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2019; 96:836-849. [DOI: 10.1016/j.kint.2019.06.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/24/2019] [Accepted: 06/27/2019] [Indexed: 11/21/2022]
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