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For Patients with End-Stage Renal Disease, Mortality After TAVR Is High

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Authors: Szerlip M et al.

J Am Coll Cardiol 2019 Jun 11 Bayliss G. J Am Coll Cardiol 2019 Jun 11

In a registry-based study, 1-year mortality with transcatheter aortic valve replacement was 37%, almost twofold higher than in patients without ESRD.

In patients receiving surgical aortic valve replacement (AVR), the presence of end-stage renal disease (ESRD) is associated with higher perioperative and later mortality. To see whether this would be also true for transcatheter AVR (TAVR), researchers analyzed data from the Society of Thoracic Surgeons (STS)/American College of Cardiology TVT Registry on all 72,631 commercial U.S. TAVR procedures performed between 2011 and 2016.

A total of 3053 patients (4.2%) had ESRD and were on dialysis. These patients were younger than those without ESRD (median age, 76 vs. 83) and more likely to be black (14.5% vs. 3.3%) and had more comorbid conditions and higher risks for surgery (STS’s Predicted Risk of Mortality scores, 13.5% vs. 6.2%). Although in-hospital mortality and procedural complications (including bleeding and vascular complications) were higher for patients with ESRD, the observed-to-expected mortality ratio was significantly lower. Longitudinal follow-up using Medicare data, available in 60% of the population, revealed incremental 1-year death rates based on renal function:

  • On dialysis, 37%
  • Nondialysis; creatinine ≥2 mg/dL, 31%
  • Nondialysis; creatinine <2 mg/dL, 18%

COMMENT

In this large registry study of TAVR in patients with renal disease, the most important finding is the surprisingly high 1-year mortality. The study has no untreated or surgical control arms; therefore, as in most studies of binary risk factors, the data are difficult to apply clinically to an individual patient with severe symptomatic aortic stenosis and ESRD who likely still has a better chance for survival with TAVR than without. Nonetheless, these findings provide a basis for shared decision making and should prompt particularly careful clinical attention to other risk factors in patients with ESRD after TAVR.

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