Severe Aortic Stenosis and Chronic Kidney Disease: Outcomes and Impact of Aortic Valve Replacement

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a revolutionary procedure for severe aortic stenosis. The coexistence of chronic kidney disease (CKD) and TAVR introduces a challenge that significantly impacts patient outcomes.

AIM

To define readmission rates, predictors, and causes after TAVR procedure in CKD stage 1-4 patients.

METHODS

We used the national readmission database 2018 and 2020 to look into readmission rates, causes and predictors after TAVR procedure in patients with CKD stage 1-4.

RESULTS

Out of 24758 who underwent TAVR and had CKD, 7892 (32.4%) patients were readmitted within 90 days, and had higher adjusted odds of being females (adjusted odds ratio: 1.17, 95%CI: 1.02-1.31, P = 0.02) with longer length of hospital stay > 6 days, and more comorbidities including but not limited to diabetes mellitus, anemia, and congestive heart failure (CHF).

CONCLUSION

Most common causes of readmission included CHF (18.0%), sepsis, and complete atrioventricular block. Controlling readmission predictors with very close follow-up is warranted to prevent such high rate of readmission.

Surgical Aortic Valve Replacement and Renal Dysfunction: From Acute Kidney Injury to Chronic Disease

Background: Surgical aortic valve replacement (SAVR) is often complicated by acute kidney injury (AKI). Identifying patients at risk of AKI is important to start nephroprotective strategies or renal replacement therapy (RRT). This study investigated the incidence and risk factors of post-operative AKI in SAVR patients. Chronic kidney disease (CKD) developed in the post-cardiac-surgery follow-up period was also assessed. Methods: A total of 462 SAVR patients were retrospectively enrolled. The primary endpoint was the occurrence rate of AKI after surgery. Kidney recovery, during two planned outpatient clinic nephrological visits within 12 months after the surgery, was assessed. Results: A total of 76 patients experienced an AKI event. A Kaplan-Meier analysis revealed that subjects with CKD stage IV had a time to progression of 2.7 days, compared to patients with stages I-II, who were characterized by the slowest progression time, >11.2 days. A Cox regression indicated that CKD stages predicted a higher risk of AKI independently of other variables. During their ICU stay, 23 patients died, representing 5% of the population, most of them requiring RRT during their ICU stay. A severe CKD before the surgery was closely related to perioperative mortality. During the follow-up period, 21 patients with AKI worsened their CKD stage. Conclusions: AKI represents a common complication for SAVR patients in the early post-operative period, prolonging their ICU stay, with negative effects on survival, especially if RRT was required. Pre-operative CKD >3 stage is an independent risk factor for AKI in patients undergoing SAVR.

Feature-Tracking-Derived Strain Analysis for Identification of Subendocardium-Involved Late Gadolinium Enhancement in Load-Induced Left Ventricular Hypertrophy: A Multicenter Study of Cardiac Magnetic Resonance Data

BACKGROUND

Subendocardium-involved late gadolinium enhancement (SILGE) is a significant predictor of poor prognosis in patients with load-induced left ventricular hypertrophy (LVH).

OBJECTIVES

This multicenter study aimed to investigate whether the diagnostic performance of cardiac magnetic resonance feature-tracking (CMR-FT)-derived strain analysis for detecting subtle subendocardial injury would be influenced by its load dependence in patients with load-induced LVH.

METHODS

A total of 149 patients with load-induced LVH were recruited from three centers and underwent enhanced CMR imaging. The patients were divided into two groups based on the presence or absence of SILGE on CMR (SILGE+ group: n = 56; SILGE- group: n = 93). Clinical and CMR parameters were evaluated in both groups.

RESULTS

The LV systolic pressure (LVSP) and LV end-diastolic pressure (LVEDP) in the SILGE+ group were higher than those in the SILGE- group (each with p < 0.05), and LVSP and LVEDP were correlated with the LV global longitudinal strain (GLS) (each with p < 0.05) in research center 1. The LV strain parameters were significantly lower in the SILGE+ group than those in the SILGE- group (each with p < 0.05). Logistic regression analysis identified GLS (OR 1.325; 95% CI 1.180 to 1.487, p < 0.001) as a predictive factor of SILGE in the patients with load-induced LVH. The receiver operating characteristic (ROC) curve analysis results indicated that the areas under the curve (AUC) of global radial strain (GRS), global circumferential strain (GCS), and GLS were 0.68, 0.69, and 0.76, respectively. De Long's test results implied that GLS had the best diagnostic performance for SILGE (p = 0.04).

CONCLUSION

Despite the load dependency of CMR-FT-derived strain analysis, the GLS exhibits reasonable accuracy in the identification of SILGE and can potentially serve as a feasible alternative for detecting subendocardial involvement in patients with load-induced LVH who are contraindicated for LGE.

Chronic kidney disease is a key risk factor for aortic stenosis progression

BACKGROUND

Rapid progression of aortic stenosis (AS) has been observed in patients undergoing dialysis, but existing cross-sectional evidence is contradictory in non-dialysis-dependent chronic kidney disease (CKD). The present study sought to evaluate whether CKD is associated with the progression of AS over time in a large cohort of patients with AS.

METHODS

We retrospectively studied all consecutive patients diagnosed with AS [peak aortic jet velocity (Vmax) ≥2.5 m/s] and left ventricular ejection fraction ≥50% in the echocardiography laboratories of two tertiary centers between 2000 and 2018. The estimated glomerular filtration rate (eGFR) (mL/min/1.73 m2) was calculated from serum creatinine values. Patients were divided into five CKD stages according to the baseline eGFR. Annual rates of change in the aortic valve area (AVA) were determined by a linear mixed-effects model.

RESULTS

Among the 647 patients included, 261 (40%) had CKD. After a median follow-up of 2.9 (interquartile range 1.8-4.8) years, the mean overall rate of change in AVA was -0.077 (95% confidence interval -0.082; -0.073) cm2/year. There was an inverse relationship between the progression rate and kidney function. The more severe the CKD stage, the greater the AVA narrowing (P < .001). By multivariable linear regression analysis, the eGFR was also negatively associated (P < .001) with AS progression. An eGFR strata below 45 mL/min/1.73 m2 was associated with higher odds of rapid progression of AS than normal kidney function. During the clinical follow-up, event-free survival (patients free of aortic valve replacement or death) decreased as CKD progressed. Rapid progression of AS in patients with kidney dysfunction was associated with worse outcomes.

CONCLUSIONS

Patients with CKD exhibit more rapid progression of AS over time and require close monitoring. The link between kidney dysfunction and rapid progression of AS is still unknown and requires further research.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in dialysis-dependent patients: a meta-analysis

OBJECTIVES

This meta-analysis aims to compare the clinical outcomes of transcatheter aortic valve implantation (TAVI) versus aortic valve replacement (AVR) for aortic stenosis in dialysis-dependent patients.

METHODS

Literature searches employed PubMed, Web of Science, Google Scholar and Embase to identify relevant studies. Bias-treated data were prioritized, isolated and pooled for analysis; raw data were utilized where bias-treated data were unavailable. Outcomes were analysed to assess for study data crossover.

RESULTS

Literature search identified 10 retrospective studies; following data source analysis, five studies were included. Upon pooling of bias-treated data, TAVI was significantly favoured in early mortality [odds ratio (OR), 0.42; 95% confidence interval (95% CI), 0.19-0.92; I2  = 92%; P  = 0.03], 1-year mortality (OR, 0.88; 95% CI 0.80-0.97; I2  = 0%; P  = 0.01), rates of stroke/cerebrovascular events (OR, 0.71; 95% CI 0.55-0.93; I2  = 0%; P  = 0.01) and blood transfusions (OR, 0.36; 95% CI 0.21-0.62; I2  = 86%; P  = 0.0002). Pooling demonstrated fewer new pacemaker implantations in the AVR group (OR, 3.33; 95% CI 1.94-5.73; I2  = 74%; P  ≤ 0.0001) and no difference in the rate of vascular complications (OR, 2.27; 95% CI 0.60-8.59; I2  = 83%; P  = 0.23). Analysis including raw data revealed the length of hospital stay to favour TAVI with a mean difference of -9.20 days (95% CI -15.58 to -2.82; I2  = 97%; P  = 0.005).

CONCLUSION

Bias-treated meta-analysis comparing surgical AVR and TAVI favoured TAVI in early mortality, 1-year mortality, rates of stroke/cerebrovascular events and blood transfusions. There was no difference in the rates of vascular complications; however, TAVI required more pacemaker implantations. Data pooling including raw data revealed that the length of hospital admission favours TAVI.

Predictors and Long-Term Prognostic Significance of Acute Renal Function Change in Patients Who Underwent Surgical Aortic Valve Replacement

There are few reports on short-term changes in renal function after surgical aortic valve replacement, and data are scarce regarding its impact on long-term outcomes. This is a retrospective study of patients who underwent isolated aortic valve replacement between 2009 and 2020 in four medical centers. Patients with end-stage renal disease were excluded. Renal function was assessed based on short-term changes. Multivariable regression models were used to identify predictors of improvement/deterioration. Cox proportional hazard models were used to assess survival trends. The study included 2402 patients, with a mean age of 69.3 years and a mean eGFR of 82.3 mL/min/1.73 m2. Short-term improvement rates were highest in stage 4 (24.4%) and stage 3 (16.8%) patients. Deterioration rates were highest in stage 1 (38.1%) and stage 2 (34.8%) patients. Deterioration in the chronic kidney disease stage was associated with a higher ten-year mortality (p < 0.001, HR 1.46); an improved stage trended toward improved survival (p = 0.14, HR 0.722). Patients with stage 3 and 4 kidney disease tended to remain stable or improve in the short term after aortic valve replacement while patients at stages 1 and 2 were at increased risk of deteriorating.

Aortic Stenosis Phenotypes and Precision Transcatheter Aortic Valve Implantation

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.

Aortic stenosis: a review on acquired pathogenesis and ominous combination with diabetes mellitus

BACKGROUND

Aortic stenosis (AS) is a progressive disease, with no pharmacological treatment. The prevalence of diabetes mellitus (DM) among AS patients is higher than in the general population. DM significantly increases the risk of AS development and progression from mild to severe. The interplay between AS and DM's mechanism is not entirely known yet.

MAIN BODY

The increased accumulation of advanced glycation end products (AGEs) was linked to increased valvular oxidative stress, inflammation, expression of coagulation factors, and signs of calcification, according to an analysis of aortic stenotic valves. It is interesting to note that in diabetic AS patients, valvular inflammation did not correlate with serum glucose levels but rather only with long-term glycemic management markers like glycated haemoglobin and fructosamine. Transcatheter aortic valve replacement, which has been shown to be safer than surgical aortic valve replacement, is advantageous for AS patients who also have concurrent diabetes. Additionally, novel anti-diabetic medications have been proposed to lower the risk of AS development in DM patients, including sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonist that target reduction of AGEs-mediated oxidative stress.

CONCLUSIONS

There are little data on the effects of hyperglycemia on valvular calcification, but understanding the interactions between them is essential to develop a successful treatment strategy to stop or at least slow the progression of AS in DM patients. There is a link among AS and DM and that DM negatively impacts the quality of life and longevity of AS patients. The sole successful treatment, despite ongoing efforts to find new therapeutic modalities, involves aortic valve replacement. More research is required to find methods that can slow the advancement of these conditions, enhancing the prognosis and course of people with AS and DM.

Indoxyl-sulfate activation of the AhR- NF-κB pathway promotes interleukin-6 secretion and the subsequent osteogenic differentiation of human valvular interstitial cells from the aortic valve

BACKGROUND

Calcific aortic stenosis (CAS) is more prevalent, occurs earlier, progresses faster and has worse outcomes in patients with chronic kidney disease (CKD). The uremic toxin indoxyl sulfate (IS) is powerful predictor of cardiovascular mortality in these patients and a strong promoter of ectopic calcification whose role in CAS remains poorly studied. The objective of this study was to evaluate whether IS influences the mineralization of primary human valvular interstitial cells (hVICs) from the aortic valve.

METHODS

Primary hVICs were exposed to increasing concentrations of IS in osteogenic medium (OM). The hVICs' osteogenic transition was monitored by qRT-PCRs for BMP2 and RUNX2 mRNA. Cell mineralization was assayed using the o-cresolphthalein complexone method. Inflammation was assessed by monitoring NF-κB activation using Western blots as well as IL-1β, IL-6 and TNF-α secretion by ELISAs. Small interfering RNA (siRNA) approaches enabled us to determine which signaling pathways were involved.

RESULTS

Indoxyl-sulfate increased OM-induced hVICs osteogenic transition and calcification in a concentration-dependent manner. This effect was blocked by silencing the receptor for IS (the aryl hydrocarbon receptor, AhR). Exposure to IS promoted p65 phosphorylation, the blockade of which inhibited IS-induced mineralization. Exposure to IS promoted IL-6 secretion by hVICs, a phenomenon blocked by silencing AhR or p65. Incubation with an anti-IL-6 antibody neutralized IS's pro-calcific effects.

CONCLUSION

IS promotes hVIC mineralization through AhR-dependent activation of the NF-κB pathway and the subsequent release of IL-6. Further research should seek to determine whether targeting inflammatory pathways can reduce the onset and progression of CKD-related CAS.

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.

Transcatheter Aortic Valve Replacement in Special Populations

Since its food and drug administration (FDA) approval in 2011, transcatheter aortic valve replacement (TAVR) has revolutionized the highly prevalent disease of aortic stenosis. In this review, we present a comprehensive overview of the data and considerations for utilization of TAVR in special populations who were either excluded from or not adequately represented in the seminal TAVR trials, due to high-risk valvular and/or systemic factors. These include nonagenarians, patients with renal dysfunction, chronic thrombocytopenia, bicuspid aortic valve, rheumatic valve disease, patients with failed aortic valve bioprosthesis requiring valve-in-valve intervention and patients with mixed aortic valve disease. In short, TAVR is a feasible therapeutic strategy in high-risk and special populations with mortality benefit and improvement in quality of life. Randomized controlled trials in high-risk populations are recommended to confirm results from observational studies.

Technical Success after Transcatheter Aortic Valve Replacement for Bicuspid versus Tricuspid Aortic Stenosis

Background: Comparative data of the Valve Academic Research Consortium (VARC-3)-defined technical success between bicuspid versus tricuspid aortic stenosis (AS) remain lacking. Aims: We sought to compare the technical success and other clinical outcomes between patients with bicuspid and tricuspid AS receiving transcatheter aortic valve replacement. Methods: A registration-based analysis was performed for 402 patients (211 and 191 cases of bicuspid and tricuspid AS, respectively). The primary outcome was VARC-3-defined technical success. Additional analysis was performed to assess outcomes for up to one year between the two groups. Results: Bicuspid AS patients tended to be younger (74 years vs. 77 years; p < 0.001) with a lower Society of Thoracic Surgeons score (4.4% vs. 5.4%; p = 0.003). Bicuspid AS patients showed a lower prevalence of hypertension and peripheral vascular diseases. Technical failure was encountered in 17.7% of these patients, driven primarily by the high incidence of second valve implantation. The technical success rates were comparable between the bicuspid and tricuspid AS groups (82.5% vs. 82.2%, p = 0.944). Chronic kidney disease (CKD) and larger sinotubular junctional diameter (STJ) were identified as predictors of technical failure, whereas CKD, impaired left ventricular ejection fraction (LVEF), along with larger STJ, were predictors of cardiac technical failure. Technical failure was associated with an increased risk of all-cause mortality at 30 days and 1 year, as evidenced by the Cox multivariable analysis. Conclusions: No significant differences were observed in the technical success rates and most clinical outcomes between the bicuspid and tricuspid AS groups. Technical failure conferred an increased risk for both 30-day and 1-year all-cause mortalities.

Renal outcomes in valve-in-valve transcatheter versus redo surgical aortic valve replacement: A systematic review and meta-analysis

INTRODUCTION

Postoperative acute kidney injury (AKI) and the requirement for renal replacement therapy (RRT) remain common and significant complications of both transcatheter valve-in-valve aortic valve replacement (ViV-TAVR) and redo surgical aortic valve replacement (SAVR). Nevertheless, the understanding of renal outcomes in the population undergoing either redo SAVR or ViV-TAVR remains controversial.

METHODS

A systematic database search with meta-analysis was conducted of comparative original articles of ViV-TAVR versus redo SAVR in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to September 2021. Primary outcomes were AKI and RRT. Secondary outcomes were stroke, major bleeding, pacemaker implantation rate, operative mortality, and 30-day mortality.

RESULTS

Our search yielded 5435 relevant studies. Eighteen studies met the inclusion criteria with a total of 11,198 patients. We found ViV-TAVR to be associated with lower rates of AKI, postoperative RRT, major bleeding, pacemaker implantation, operative mortality, and 30-day mortality. No significant difference was observed in terms of stroke rate. The mean incidence of AKI in ViV-TAVR was 6.95% (±6%) and in redo SAVR was 15.2% (±9.6%). For RRT, our data showed that VIV-TAVR to be 1.48% (±1.46%) and redo SAVR to be 8.54% (±8.06%).

CONCLUSION

Renoprotective strategies should be put into place to prevent and reduce AKI incidence regardless of the treatment modality. Patients undergoing re-intervention for the aortic valve constitute a high-risk and frail population in which ViV-TAVR demonstrated it might be a feasible option for carefully selected patients. Long-term follow-up data and randomized control trials will be needed to evaluate mortality and morbidity outcomes between these 2 treatments.

Long-Term Outcomes of Bioprosthetic or Mechanical Valve Replacement in End-Stage Renal Disease: A Nationwide Population-Based Retrospective Study

Background: Valve replacement is associated with worse outcomes in individuals who have end-stage renal disease (ESRD) and require a long-term renal replacement therapy. Prosthetic valve selection in patients with ESRD has remained controversial.

Objective: We aimed to investigate long-term outcomes of mechanical and bioprosthetic valve replacement in individuals with ESRD.

Methods: We conducted a population-based retrospective cohort study using data obtained from the Taiwan National Health Insurance Research Database. In total, 10,202 patients, including 912 ESRD and 9,290 non-ESRD patients, were selected after a 1:1 propensity-score matching based on the type of prosthetic valve used. The long-term mortality outcomes were then analyzed.

Results: During a median follow-up period of 59.6 months, the Kaplan–Meier survival analysis revealed that ESRD patients who underwent mechanical valve replacement had higher rates of all-cause mortality and CV deaths than those who underwent bioprosthetic valve replacement (Log-rank test, p = 0.03 and 0.02, respectively). Multivariable regression analyses demonstrated that ESRD patients who underwent bioprosthetic valve replacement had lower rates of all-cause mortality (p &lt; 0.001, hazard ratio: 0.88, 95% confidence interval: 0.82–0.93) and cardiovascular (CV) death (p &lt; 0.001, hazard ratio: 0.83, 95% confidence interval: 0.76–0.90) than those who had mechanical valve replacement.

Conclusion: Bioprosthetic valve replacement is significantly associated with lower rates of all-cause mortality and CV death in the ESRD population.

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.

Cardiac Surgery 2020 Reviewed

In 2020, nearly 30,000 published references appeared in the PubMed for the search term "cardiac surgery." While SARS-CoV-2 affected the number of surgical procedures, it did not affect outcomes reporting. Using the PRISMA approach, we selected relevant publications and prepared a results-oriented summary. We reviewed primarily the fields of coronary and conventional valve surgery and their overlap with interventional alternatives. The coronary field started with a discussion on trial data value and their interpretation. Registry comparisons of coronary artery bypass surgery (CABG) and percutaneous coronary intervention confirmed outcomes for severe coronary artery disease and advanced comorbidities with CABG. Multiple arterial grafting was best. In aortic valve surgery, meta-analyses of randomized trials report that transcatheter aortic valve implantation may provide a short-term advantage but long-term survival may be better with classic aortic valve replacement (AVR). Minimally invasive AVR and decellularized homografts emerged as hopeful techniques. In mitral and tricuspid valve surgery, excellent perioperative and long-term outcomes were presented for structural mitral regurgitation. For both, coronary and valve surgery, outcomes are strongly dependent on surgeon expertise. Kidney disease increases perioperative risk, but does not limit the surgical treatment effect. Finally, a cursory look is thrown on aortic, transplant, and assist-device surgery with a glimpse into the current stand of xenotransplantation. As in recent years, this article summarizes publications perceived as important by us. It does not expect to be complete and cannot be free of individual interpretation. We aimed to provide up-to-date information for decision-making and patient information.

Diabetes Mellitus and Its Implications in Aortic Stenosis Patients

Aortic stenosis (AS) and diabetes mellitus (DM) are both progressive diseases that if left untreated, result in significant morbidity and mortality. Several studies revealed that the prevalence of DM is substantially higher in patients with AS and, thus, the progression from mild to severe AS is greater in those patients with DM. DM and common comorbidities associated with both diseases, DM and AS, increase patient management complexity and make aortic valve replacement the only effective treatment. For that reason, a better understanding of the pathogenesis underlying both these diseases and the relationships between them is necessary to design more appropriate preventive and therapeutic approaches. In this review, we provided an overview of the main aspects of the relationship between AS and DM, including common comorbidities and risk factors. We also discuss the established treatments/therapies in patients with AS and DM.

Severe Aortic Stenosis and Chronic Kidney Disease: Outcomes and Impact of Aortic Valve Replacement

Background

The prognostic significance of chronic kidney disease (CKD) in severe aortic stenosis is poorly understood and no studies have yet evaluated the effect of aortic‐valve replacement (AVR) versus conservative management on long‐term mortality by stage of CKD.

Methods and Results

We included 4119 patients with severe aortic stenosis. The population was divided into 4 groups according to the baseline estimated glomerular filtration rate: no CKD, mild CKD, moderate CKD, and severe CKD. The 5‐year survival rate was 71±1% for patients without CKD, 62±2% for those with mild CKD, 54±3% for those with moderate CKD, and 34±4% for those with severe CKD (P<0.001). By multivariable analysis, patients with moderate or severe CKD had a significantly higher risk of all‐cause (hazard ratio [HR] [95% CI]=1.36 [1.08–1.71]; P=0.009 and HR [95% CI]=2.16 [1.67–2.79]; P<0.001, respectively) and cardiovascular mortality (HR [95% CI]=1.39 [1.03–1.88]; P=0.031 and HR [95% CI]=1.69 [1.18–2.41]; P=0.004, respectively) than patients without CKD. Despite more symptoms, AVR was less frequent in moderate (P=0.002) and severe CKD (P<0.001). AVR was associated with a marked reduction in all‐cause and cardiovascular mortality versus conservative management for each CKD group (all P<0.001). The joint‐test showed no interaction between AVR and CKD stages (P=0.676) indicating a nondifferentialeffect of AVR across stages of CKD. After propensity matching, AVR was still associated with substantially better survival for each CKD stage relative to conservative management (all P<0.0017).

Conclusions

In severe aortic stenosis, moderate and severe CKD are associated with increased mortality and decreased referral to AVR. AVR markedly reduces all‐cause and cardiovascular mortality, regardless of the CKD stage. Therefore, CKD should not discourage physicians from considering AVR.