Prosthesis type has minimal impact on survival after valve surgery in patients with moderate to end-stage renal failure

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis

BACKGROUND

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.

METHODS

Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.

RESULTS

Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.

CONCLUSIONS

In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection

OBJECTIVE

Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection.

METHODS

Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms.

RESULTS

Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001).

CONCLUSIONS

Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.

Surgical Explantation of a Transcatheter-Implanted Aortic Valve Prosthesis Is Feasible and Easy

This report describes a clinical case of a degenerated CoreValve (Medtronic, Minneapolis, MN) aortic prosthesis in a 59-year-old patient. Videos of a previously described surgical technique for late surgical explantation of a CoreValve are provided. This operation is feasible and easy to perform, partly because of the absence of adhesions at the coronary ostia. This report also comments on the controversy between mechanical and biologic prostheses in patients undergoing renal dialysis.

Tissue valves are preferable for patients with end-stage renal disease: an aggregate meta-analysis

BACKGROUND

Valve selection in patients with end-stage renal disease (ESRD) is uncertain. We performed a systematic review and meta-analysis to compare clinical outcome in ESRD patients undergoing valve replacement.

METHODS

We systematically searched multiple databases (2000-October 2015) to identify original studies comparing adverse events between mechanical and biological valve replacement in ESRD patients. End-points studied were: postoperative mortality, bleeding events, need for re-operation, and late survival. A random-effect inverse-variance weighted analysis was performed; event rates are compared as odds ratio (OR and 95% confidence interval) and hazard ratios (HR) for time-to-event data. Mechanical valve and tissue valve replacement were considered as study and control cohorts, respectively.

RESULTS

Fifteen retrospective studies (5523 mechanical and 1600 tissue valve) were included in our meta-analysis. Early mortality was comparable (OR 1.15 [0.77; 1.72]; p = 0.49). The mean follow-up among studies ranged from 1.6-15 years. Bleeding was significantly higher after mechanical valve replacement (OR 2.55 [1.53; 4.26]; p = 0.0003). Structural valve degeneration was present in only 0.6% patients after a tissue valve replacement. Overall survival after valve replacement was poor (median 2.61 years); valve choice did not influence this outcome (pooled HR 0.87 [0.73; 1.04]; p = 0.14).

CONCLUSION

Operative mortality in ESRD patients is comparable between mechanical and tissue valve replacement. Major bleeding episodes are significantly higher after mechanical valve replacement but structural degeneration in tissue valves during the follow-up period is low. Based on the findings from this meta-analysis, we would recommend using tissue valves in patients with ESRD.

Bioprosthetic versus mechanical prostheses for valve replacement in end-stage renal disease patients: systematic review and meta-analysis

BACKGROUND

Patients with end-stage renal disease (ESRD) indicated for dialysis are increasingly requiring cardiac valve surgery. The choice of bioprosthetic or mechanic valve prosthesis for such patients requires careful risk assessment. A systematic review and meta-analysis was performed to assess current evidence available.

METHODS

A comprehensive search from six electronic databases was performed from their inception to February 2015. Results from patients with ESRD undergoing cardiac surgery for bioprosthetic or mechanical valve replacement were identified.

RESULTS

Sixteen studies with 8,483 patients with ESRD undergoing cardiac valve replacement surgery were included. No evidence of publication bias was detected. Prior angioplasty by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery was significantly higher in the bioprosthetic group compared to the mechanical group (16.0% vs. 12.0%, P=0.04); all other preoperative baseline patient characteristics were similar. There was no significant difference in 30-day mortality or all-cause mortality between the two comparisons. Compared with the mechanical group, the frequency of bleeding (5.2% vs. 6.4%, P=0.04) and risk of thromboembolism (2.7% vs. 12.8%, P=0.02) were significantly lower in the bioprosthetic group. There were similar rates of reoperation and valve endocarditis.

CONCLUSIONS

The present study demonstrated that patients with ESRD undergoing bioprosthetic or mechanical valve replacement had similar mid-long term survival. The bioprosthetic group had lower rates of bleeding and thromboembolism. Further studies are required to differentiate the impact of valve location. The presented results may be applicable for ESRD patients requiring prosthetic valve replacement.

Impact of valvular prosthesis type on cardiovascular outcomes in patients on chronic dialysis

There is conflicting evidence guiding valve prosthesis selection in patients with end-stage renal disease on dialysis. We sought to determine, after reviewing the relevant literature, the best valve substitute in patients on chronic dialysis. A total of 9 retrospective studies compared the outcomes of two valves, showing similar results and highlighting the safety of implanting bioprostheses in patients on chronic dialysis. Standards of valve selection have changed over time; it has long been believed that tissue valves undergo premature degeneration due to calcium metabolism derangements in patients with end-stage renal disease. Bleeding was the most common valve-related complication and represented a major drawback of mechanical valves. Two studies demonstrated a survival advantage in favour of mechanical prostheses. It can be concluded that surgeons should not hesitate to implant bioprostheses because singular valve decomposition would be uncommon in this patient population. Prosthesis selection should be based on the same criteria as those used for non-dialysis patients.

Prognostic value of chronic kidney disease after transcatheter aortic valve implantation

OBJECTIVES

This study sought to assess the influence of chronic kidney disease (CKD) classification on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI).

BACKGROUND

The prognostic value of impaired renal function according to CKD classification has not been thoroughly investigated in very elderly TAVI cohorts.

METHODS

Data from 642 consecutive patients who underwent TAVI were prospectively collected. Clinical outcomes were compared in enrolled patients, divided into CKD stage 1+2, CKD stage 3a, CKD stage 3b, and CKD stage 4 on the basis of estimated glomerular filtration rate ≥60, 45 to 59, 30 to 44, and 15 to 29 ml/min/1.73 m(2), respectively.

RESULTS

Among the study patients (mean age: 83.5 ± 6.5 years, logistic European System for Cardiac Operative Risk Evaluation score 20.0% [range: 13.6% to 28.8%]), 34% were categorized as CKD stage 1+2 (n = 218), 28.3% as CKD stage 3a (n = 182), 28.2% as CKD stage 3b (n = 181), and 9.5% as CKD stage 4 (n = 61). Thirty-day and cumulative 1-year mortality rates increased significantly across the 4 groups (6.9% vs. 8.8% vs. 13.3% vs. 26.2%, p = 0.002, and 17.2% vs. 23.4% vs. 29.2% vs. 47.8%, p < 0.001, respectively). After adjustment for considerable influential confounders in a Cox multivariate regression model, CKD stage 4 was associated with increased risk for 30-day mortality (hazard ratio: 3.04; 95% confidence interval [CI]: 1.43 to 6.49; p = 0.004), and CKD stages 3b and 4 were related to increased cumulative 1-year mortality (hazard ratios: 1.71 and 2.91; 95% CI: 1.09 to 2.68 and 1.73 to 4.90; p = 0.020 and p < 0.001, respectively) compared with CKD stage 1+2 as the referent.

CONCLUSIONS

Classification of CKD stages before TAVI allows risk stratification for early and midterm clinical outcomes. TAVI for patients with CKD stage 4 is still considered challenging because of high mortality rates after the procedure.

Are bioprostheses associated with better outcome than mechanical valves in patients with chronic kidney disease requiring dialysis who undergo valve surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with chronic kidney disease who required dialysis that undergo valve surgery have better surgical recovery rates with bioprostheses than with mechanical valves. Altogether more than 96 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Patients with end stage renal disease (ESRD) undergoing cardiac surgery are very fragile, with high in-hospital mortality rates (13-36%) and limited life expectancy (15-42 months in selected studies). Two studies outlined that diabetic ESRD, neurological impairment, age at the operation and poor ventricular function are the strongest predictors of early and late morbidity and mortality. Based on American Heart Association/American College of Cardiology (AHA/ACC) 1998 valvular guidelines, bioprostheses were considered a contraindication in dialysis patients; this statement derived from anecdotal reports of accelerated valve degeneration. Structural valve deterioration was reported in only 5 of 1347 patients who received bioprosthesis through the studies and independent from implantation site. Likelihood of degeneration is low, with a calculated valve-excision rate of 7%, and occurred in a broad range of time (from 10 to 156 months). The AHA/ACC 2006 valvular revised guidelines removed the previous statement (1998) of class IIa recommendation for mechanical valves and class III for tissue valves; in the focus update of 2008, there is still no specific indication for valve selection in dialysis patients, but difficulties in maintaining anticoagulation in these patients was noted. Stroke, haemorrhage and gastro-intestinal bleeding events occurred in almost 15% of patients with mechanical valves during the follow-up, while bioprostheses showed an average event rate of 3.9%. All but one of the selected studies reported no differences in survival between mechanical and biological valves; in five of seven studies, the patients who received bioprostheses were older (mechanical vs biological average 53 years vs 61.4 years), in one study, patients had undergone dialysis for longer period of time, and, in another study, they had suffered from more previous myocardial infarction (mechanical vs biological 9.1% vs 36.2%). Therefore, survivals have been biased in favour of mechanical valves. Taking together these data, biological valves are a suitable treatment for dialysis-dependent patients and, while not superior to mechanical valves in survival due to the aforementioned study biases, exhibit lower valve-related and anti-coagulation related events.

Should we use mechanical valves in patients with end-stage renal disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a mechanical or bioprosthetic valve is superior for immediate and long-term survival in patients with end-stage renal disease (ESRD) undergoing a valve replacement. Altogether more than 150 papers were found using the reported search; of which, eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were no randomized controlled trials addressing the question. There was one systematic review and meta-analysis. All the other evidence was in the form of retrospective studies. The papers show that there is no significant difference in the results and survival between patients receiving a mechanical and those receiving a bioprosthetic valve. This was seen in the meta-analysis as well as the larger series of patients who underwent valve replacement. Bleeding complications were more common with mechanical valves. We conclude that the choice of valve for patients with ESRD should be determined by age, level of activity and patient choice. Due to the limited life expectancy of these patients, bioprosthetic valves should be considered, especially since there is no evidence of early degeneration of tissue valves in this subgroup of patients.