Impact of Pre-existing Kidney Dysfunction on Outcomes Following Transcatheter Aortic Valve Replacement

Evolving Paradigms in Transcatheter Aortic Valve Replacement: Results from a High-Volume, Single Center Experience

Given the expanding indications toward younger patients at lower surgical risk, transcatheter aortic valve replacement (TAVR) simplification and streamlining are gaining increasing importance. Patients who underwent TAVR from the year 2015 to 2020 were prospectively enrolled. The patients were divided in time tertiles according to the date of intervention. Data on preprocedural planning, including coronary computed tomography angiography (CCTA), procedures, and outcomes, were compared between the time tertiles. A total of 771 consecutive patients from a single institution were enrolled. We observed a trend toward the use of a fully percutaneous versus surgical approach for the index access, left radial artery versus contralateral femoral artery for the secondary access, and left ventricular pacing on the stiff guidewire versus right ventricular pacing. Immediate device success significantly increased, whereas the length of hospital stay decreased. Overall, approximately 60% of the total study population underwent CCTA instead of coronary angiography, with no adverse events. One-year survival rates significantly improved over time. A simplified TAVR approach was associated with better survival, whereas low baseline functional capacity, preexisting coronary artery disease, renal impairment, periprocedural blood transfusions, and paravalvular leak were related to worse outcomes. In conclusion, our study showed a constant tendency to procedure streamlining and improve procedural success and 1-year outcomes. A strategy based on CCTA allows sparing safely almost half of the preoperative invasive coronary angiography.

Significance of Kidney Disease in Cardiovascular Disease Patients

Cardiorenal syndrome is a condition where is a bidirectional and mutually detrimental relationship between the heart and kidneys. The mechanisms underlying cardiorenal syndrome are multifactorial and complex. Patients with kidney disease exhibit increased cardiovascular risk, presenting as coronary and peripheral artery disease, structural heart disease, arrhythmias, heart failure, and sudden cardiac death, largely occurring because of a systemic proinflammatory state, causing myocardial and vascular remodeling, manifesting as atherosclerotic lesions, vascular and valvular calcification, and myocardial fibrosis, particularly among those with advanced disease. This review summarizes the current understanding and clinical implications of kidney disease in patients with cardiovascular disease.

Renal Function-Based Contrast Threshold Predicts Kidney Injury in Transcatheter Aortic Valve Replacement

Background

Acute kidney injury (AKI) after contrast-guided interventions is associated with adverse outcomes, but the role of contrast in the context of renal function is less well described for patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

Patients from the Michigan TAVR registry between January 2016 and December 2019 were included. AKI was defined using Valve Academic Research Consortium 2 definitions. An integer cut point for the ratio of contrast volume (CV) to renal function (estimated glomerular filtration rate [eGFR]) as a predictor of AKI was calculated.

Results

Of 7112 cases, AKI occurred in 629 (8.8%) patients. Unadjusted mortality was higher among patients with AKI (32.5% vs 9.0%, P ​< ​.0001). AKI remained significantly associated with the risk of mortality after multivariable adjustment (hazard ratio = 4.50, P ​< ​.001). Procedural characteristics associated with AKI included CV/eGFR >2 (adjusted odds ratio [aOR] = 1.36, P = .003, 95% CI = 1.10-1.67), CV/eGFR >3 (aOR = 1.38, P ​= ​.009, 95% CI = 1.09-1.77), and use of general anesthesia (aOR = 1.67, P ​< ​.0001, 95% CI = 1.38-2.03).

Conclusions

CV in the context of renal function administrated during TAVR is a robust tool to predict AKI. AKI after TAVR is associated with an increased risk of mortality. Incorporation of thresholds of >2× and > 3× eGFR into procedural planning should be considered as a quality initiative.

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.

Preoperative heart failure worsens outcome after aortic valve replacement irrespective of left ventricular ejection fraction

BACKGROUND

Left ventricular ejection fraction (LVEF) affects outcome of valve replacement (AVR) in aortic stenosis (AS). The study aim was to investigate the prognostic importance of concomitant cardiovascular disease in relation to preoperative LVEF.

METHODS AND RESULTS

All adult patients undergoing AVR due to AS 2008-2014 in a national register for heart diseases were included. All-cause mortality and hospitalization for heart failure during follow-up after AVR, stratified by preserved or reduced LVEF (=50%), was derived from national patient registers and analyzed by Cox regression.During the study period 10,406 patients, median age 73 years, a median follow-up of 35 months were identified. Preserved LVEF was present in 7,512 (72.2%). Among them 647 (8.6%) had a history of heart failure (HF) and 1,099 (14.6%) atrial fibrillation (AF) before intervention. Preoperative HF was associated with higher mortality irrespective of preserved or reduced LVEF: Hazard Ratio (HR) 1.64 (95% C.I. 1.35 -1.99) and 1.58 (95% C.I. 1.30 -1.92). Prior AF was associated with a higher risk of mortality in patients with preserved but not in those with reduced LVEF: HR 1.62 (95% C.I. 1.36 -1.92) and 1.05 (95% C.I. 0.86 -1.28). Irrespective of LVEF preoperative HF and AF were associated with an increased risk of postoperative heart failure hospitalization.

CONCLUSION

In patients planned for AVR, a history of HF or AF, irrespective of LVEF, worsens the postoperative prognosis. HF and AF can be seen as markers of myocardial fibrosis not necessarily discovered by LVEF and the merely use of it, besides symptoms, for timing of AVR seems suboptimal.

Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice

Objective

Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR.

Methods

Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR.

Results

Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR.

Conclusions

There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.

Transcatheter Versus Surgical Aortic Valve Replacement in Renal Transplant Patients: A Meta-Analysis

Background

The outcome of transcutaneous aortic valve replacement (TAVR) in patients with kidney transplant is unknown, as majority of these patients were excluded from the major TAVR clinical trials. We sought to compare patients with severe aortic stenosis who underwent TAVR versus surgical aortic valve replacement (SAVR) with a history of kidney transplant.

Methods

PubMed, Google Scholar and Cochrane databases were searched to identify relevant articles. The incidence of all-cause mortality and acute kidney injury (AKI) was calculated using relative risk on a random effect model.

Results

A total of 1,538 patients (TAVR 328, SAVR 1,210) were included in the study. TAVR was associated with lower mortality as compared with SAVR at 30 days from the index procedure (odds ratio (OR) 0.48, 95% confidence interval (CI): 0.25 - 0.93; P = 0.03). One-year mortality was studied in three studies and showed comparable mortality in patients undergoing TAVR and SAVR (OR: 0.76, 95% CI: 0.10 - 5.51; P = 0.78). Compared to SAVR, TAVR carries an identical risk of AKI (OR: 0.44, 95% CI: 0.10 - 1.90; P = 0.27). A sensitivity analysis performed by exclusion of Voudris et al study showed a non-significant difference in the mortality incidence of two groups at 30 days (OR: 0.72, 95% CI: 0.27 - 1.91; P = 0.51).

Conclusions

In patients with a history of kidney transplant, TAVR was associated with a comparable risk of mortality and AKI compared to SAVR.

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

Objective Our study aimed to assess the risk of in-patient mortality due to renal failure and other comorbidities in aortic stenosis (AS) patients undergoing transcatheter aortic valve replacement (TAVR). Methods We conducted a cross-sectional study using a Nationwide Inpatient Sample (NIS, January 2010 to December 2014) from the United States and included 33,325 patients with a primary diagnosis of AS. Logistic regression was used to evaluate the odds ratio (OR) for in-hospital mortality in AS by comorbidities including renal failure. Results The prevalence of renal failure in AS patients is 29.2%, and a higher proportion were males (60.1%) and non-white (14.1%). Major loss of function (96.6%) and in-hospital mortality (5.1%) were also proportionally higher in prevalence. Female patients (OR 1.35, 95% CI 1.20-1.51) had higher odds of in-patient mortality in AS patients. Race was a non-significant predictor for mortality risk. Patients with comorbid coagulopathy (OR 2.02, 95% CI 1.79-2.27) and heart failure (OR 1.62, 95% CI 1.39-1.89) have increased mortality in AS inpatients. After controlling confounders, renal failure was significantly associated with increased in-hospital mortality (OR 1.43, 95% CI 1.28-1.61) in AS patients. Conclusion Renal failure was prevalent in AS patients and was an independent factor that increases the risk of in-hospital mortality by 43%. Due to worse outcomes, more studies are required to evaluate risk-benefit ratio and strategies to improve health-related quality of life in post-TAVR patients with renal failure, and optimally decrease inpatient mortality.