Patients with dialysis-dependent end-stage renal disease (ESRD) exhibit high rates of perioperative complications and early mortality after surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has been considered an alternative for high-risk and inoperable patients. But results from a large study on the topic suggest TAVR is risky for patients on dialysis.
In a study of 3053 aortic stenosis patients undergoing TAVR, dialysis patients had a significantly higher 1-year mortality rate in adjusted analyses than nondialysis patients: 36.8% vs 18.7%. ESRD patients also had significantly higher in-hospital mortality 5.1% vs 3.4%, Molly Szerlip, MD, of Baylor Scott and White Health in Plano, Texas, and colleagues reported the Journal of the American College of Cardiology.
Dialysis patients suffered major vascular complications to the same degree as their counterparts (4.5% vs 4.6%), but they had a significantly higher rate of major bleeding (1.4% vs 1.0%). They also had significantly higher rates of comorbidities, such as hypertension, diabetes mellitus, peripheral arterial disease, previous myocardial infarction, and heart failure. The team found no difference in the prevalence of stroke, atrial fibrillation, or prior coronary revascularization. Despite ESRD patients’ younger age (76 vs 83 years), they had higher predicted mortality risk according to the Society of Thoracic Surgeons’ procedural operative mortality calculator: 13.5% vs 6.2% on median.
“The 1-year survival raises concerns regarding diminished benefit in this population,” Dr Szerlip and her team wrote. “TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis.”
George Bayliss, MD, of Rhode Island Hospital and Alpert Medical School of Brown University, both in Providence, Rhode Island, concurred in an accompanying editorial: “Although ESRD may not be an absolute contraindication to TAVR, just because we can replace the valve does not mean we should in every dialysis patient with severe AS [aortic stenosis]. More data is needed to identify a probably small subset of ESRD patients with AS who are too sick to undergo surgical repair, yet who would benefit from a TAVR. Even then, those patients and their families need to know that the procedure carries high risk and may, at best, only buy a little more time.”
Szerlip M, Zajarias A, Vemalapalli S, et al. Transcatheter aortic valve replacement in patients with end-stage renal disease. J Am Coll Cardiol. 2019;73:2806–15. doi:10.1016/j.jacc.2019.03.496
Bayliss G. TAVR in Patients with end-stage renal disease and critical aortic stenosis: Hard choices. J Am Coll Cardiol. doi:10.1016/j.jacc.2019.04.007