There Is Poor Survival In Hemodialysis Dependent Patients Undergoing Transcatheter Aortic Valve Replacement
Joshua L. Manghelli, Daniel I. Carter, Ali J. Khiabani, Robert M. MacGregor, John M. Lasala, Alan Zajarias, Ralph J. Damiano, Hersh S. Maniar, Spencer J. Melby.
Washington University In St. Louis, St. Louis, MO, USA.
Background Dialysis dependent patients undergoing aortic valve replacement (AVR) for aortic stenosis have poor short term survival. Many patients who could benefit from aortic valve replacement are deemed at elevated risk to undergo standard surgery. Transcatheter aortic valve replacement (TAVR) has proven to be a good option for these patients but there is little data on outcomes. Our goal was to assess morbidity and short-term mortality of dialysis dependent patients who were deemed at elevated risk for surgery and underwent TAVR. Methods A retrospective study of all dialysis-dependent patients undergoing TAVR over a 7 year period at two institutions was performed. Baseline characteristics, perioperative outcomes and follow-up echocardiographic data were examined. Survival was determined using the Kaplan Meier method. Variables are reported as mean ± SD. Paired samples T-test was used to determine differences between continuous variables. Results Forty seven patients, 31(66%) who were male, underwent TAVR at two academic institutions during the 7 year period. Average age was 73.8±9.1. Preoperative EuroScore II was 11.4±8.2%. Forty-one of the 47 (87%) patients had NYHA class III or IV symptoms prior to TAVR. Twenty-six patients (55%) had peripheral vascular disease, 15/47 (32%) had chronic lung disease, and 29/47 (61%) had diabetes mellitus. Preoperative ejection fraction was 47.9±16.7 %. Three patients (6%) suffered a postoperative stroke, 4 patients (9%) developed postoperative atrial fibrillation, and 2 patients (4%) had cardiac arrest. Seven patients (15%) died within 30 days. Survival at 1 and 2 years was 72% and 49%, respectively (Figure). By comparison, the 1 and 2 year survival for 237 patients on hemodialysis who underwent surgical AVR in the same time period was 64% and 55%, respectively. At a mean follow up time of 12.1±11.1 months postoperatively, mean ejection fraction increased to 52.1 ±14.1 (p=0.016). Conclusion Dialysis-dependent patients who had TAVR had poor operative and short-term survival. This was similar to patients who underwent surgical aortic valve replacement. These poor short-term outcomes should temper enthusiasm for AVR, either transcatheter or surgical, in this patient population; careful patient selection is needed. A study to determine specific variables which dictate poor outcomes is warranted. 
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