Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease

Background: In patients with end-stage renal disease (ESRD), surgical aortic valve replacement is associated with higher early and late mortality, and adverse outcomes compared with patients without renal disease. Transcatheter aortic valve replacement (TAVR)offers another alternative, but there are limited reported outcomes. Objectives: The purpose of this study was to determine the outcomes of TAVR in patients with ESRD. Methods: Among the first 72,631 patients with severe aortic stenosis (AS)treated with TAVR enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC)TVT (Transcatheter Valve Therapies)registry, 3,053 (4.2%)patients had ESRD and were compared with patients who were not on dialysis for demographics, risk factors, and outcomes. Results: Compared with the nondialysis patients, ESRD patients were younger (76 years vs. 83 years; p < 0.01)and had higher rates of comorbidities leading to a higher STS predicted risk of mortality (median 13.5% vs. 6.2%; p < 0.01). ESRD patients had a higher in-hospital mortality (5.1% vs. 3.4%; p < 0.01), although the observed to expected ratio was lower (0.32 vs. 0.44; p < 0.01). ESRD patients also had a similar rate of major vascular complications (4.5% vs. 4.6%; p = 0.86), but a higher rate of major bleeding (1.4% vs. 1.0%; p = 0.03). The 1-year mortality was significantly higher in dialysis patients (36.8% vs. 18.7%; p < 0.01). Conclusions: Patients undergoing TAVR with ESRD are at higher risk and had higher in-hospital mortality and bleeding, but similar vascular complications, when compared with those who are not dialysis dependent. The 1-year survival raises concerns regarding diminished benefit in this population. TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis.