Prosthesis type has minimal impact on survival after valve surgery in patients with moderate to end-stage renal failure.

Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
Nephrology Dialysis Transplantation (Impact Factor: 3.37). 08/2008; 23(11):3613-21. DOI: 10.1093/ndt/gfn337
Source: PubMed

ABSTRACT Few previous studies have reported on the outcome of patients with renal failure (RF) undergoing valvular surgery, particularly with regard to choice of valve prosthesis.
We retrospectively analyzed prospectively collected data from 155 patients with RF (mean age 62 +/- 14, 42% female) who underwent left-sided valve surgery from January 1998 to December 2006. Patients were divided into two groups: Group 1 (non-dialysis-dependent renal failure (NDRF); creatinine >2.5 mg/dl; n = 47, 40%) and Group 2 (renal failure dialysis (DRF); n = 108, 60%). Mechanical valves were implanted in 50 (32%) patients and bioprostheses in 63 (41%). Isolated mitral valve reconstruction was performed in 27% (n = 42) of patients. Outcome measures included hospital mortality, major postoperative complications, length of hospital stay, discharge planning and late survival.
The overall hospital mortality was 19.3% (n = 30) and was not different between Groups 1 (23%) and 2 (18%). Ejection fraction, peripheral vascular disease, aortic valve replacement and reoperation were independent predictors of hospital mortality. One- and five-year survival rates were 74.4 +/- 7.8% and 53.1 +/- 10.1% in Group 1 and 75.8 +/- 4.6% and 49.1 +/- 7.1% in Group 2 (P = ns), respectively. According to the type of prostheses, hospital mortality and freedom from reoperation were similar in patients with mechanical and biological valves. Five-year survival rate was 51 +/- 10.7 for biological valves versus 55 +/- 8.4 for mechanical valves (P = ns).
Hospital mortality and morbidity remain high in patients with RF undergoing valvular surgery and it is not different in NDRF and DRF patients. This study suggests that the type of valve prosthesis does not appear to have an impact on early and late survival but is limited by sample size. It may be that bioprostheses should be more widely used in patients with RF requiring valve replacement.

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    ABSTRACT: A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients with chronic kidney disease who required dialysis that undergo valve surgery have better surgical recovery rates with bioprostheses than with mechanical valves. Altogether more than 96 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, rele-vant outcomes and results of these papers are tabulated. Patients with end stage renal disease (ESRD) undergoing cardiac surgery are very fragile, with high in-hospital mortality rates (13–36%) and limited life expectancy (15–42 months in selected studies). Two studies outlined that diabetic ESRD, neurological impairment, age at the operation and poor ventricular function are the strongest predictors of early and late morbidity and mortality. Based on American Heart Association/American College of Cardiology (AHA/ACC) 1998 valvular guidelines, bioprostheses were considered a contraindication in dialysis patients; this state-ment derived from anecdotal reports of accelerated valve degeneration. Structural valve deterioration was reported in only 5 of 1347 patients who received bioprosthesis through the studies and independent from implantation site. Likelihood of degeneration is low, with a calculated valve-excision rate of 7%, and occurred in a broad range of time (from 10 to 156 months). The AHA/ ACC 2006 valvular revised guidelines removed the previous statement (1998) of class IIa recommendation for mechanical valves and class III for tissue valves; in the focus update of 2008, there is still no specific indication for valve selection in dialysis patients, but difficulties in maintaining anticoagulation in these patients was noted. Stroke, haemorrhage and gastro-intestinal bleeding events occurred in almost 15% of patients with mechanical valves during the follow-up, while bioprostheses showed an average event rate of 3.9%. All but one of the selected studies reported no differences in survival between mechanical and bio-logical valves; in five of seven studies, the patients who received bioprostheses were older (mechanical vs biological average 53 years vs 61.4 years), in one study, patients had undergone dialysis for longer period of time, and, in another study, they had suf-fered from more previous myocardial infarction (mechanical vs biological 9.1% vs 36.2%). Therefore, survivals have been biased in favour of mechanical valves. Taking together these data, biological valves are a suitable treatment for dialysis-dependent patients and, while not superior to mechanical valves in survival due to the aforementioned study biases, exhibit lower valve-related and anti-coagulation related events.
    Interactive Cardiovascular and Thoracic Surgery 06/2012; 15(3). DOI:10.1093/icvts/ivs236 · 1.11 Impact Factor
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    ABSTRACT: OBJECTIVES: The aim of this study was to assess the influence of chronic kidney disease (CKD) classification on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). BACKGROUND: The prognostic value of impaired renal function according to CKD classification has not been thoroughly investigated in very elderly TAVI cohorts. METHODS: Data of 642 consecutive patients who underwent TAVI were prospectively collected. We compared the clinical outcomes of enrolled patients divided into CKD 1+2, CKD 3a, CKD 3b, and CKD 4 based on the estimated glomerular filtration rate: ≥60, 45-59, 30-44, and 15-29 ml/min/1.73m(2), respectively. RESULTS: Among the study patients [mean age: 83.5±6.5 years, logistic EuroSCORE: 20.0 (13.6-28.8), 34.0% were categorized as CKD 1+2 (n=218), 28.3% CKD 3a (n=182), 28.2% CKD 3b (n=181), and 9.5% CKD 4 (n=61)]. Both the 30-day and cumulative 1-year mortality rates increased significantly across the 4 groups (6.9% vs. 8.8% vs. 13.3% vs. 26.2%; p=0.002 and 17.2% vs. 23.4% vs. 29.2% vs. 47.8%; p<0.001, respectively). After adjustment for considerable influential confounders in COX-regression multivariate model, CKD 4 was associated with an increased risk of 30-day mortality (HR: 3.04, 95%CI: 1.43-6.49, p=0.004), and CKD 3b and 4 were related to increased cumulative 1-year mortality (HR: 1.71, 2.91; 95%CI: 1.09-2.68, 1.73-4.90; p=0.020, <0.001, respectively) when compared to CKD 1+2 as reference. CONCLUSIONS: Classification of CKD stages before TAVI allows risk stratification for early and mid-term clinical outcome. TAVI for CKD 4 patients is still considered challenging due to high mortality rates after procedure.
    Journal of the American College of Cardiology 05/2013; 62(10). DOI:10.1016/j.jacc.2013.04.057 · 15.34 Impact Factor
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    ABSTRACT: There is conflicting evidence guiding valve prosthesis selection in patients with end-stage renal disease on dialysis. We sought to determine, after reviewing the relevant literature, the best valve substitute in patients on chronic dialysis. A total of 9 retrospective studies compared the outcomes of two valves, showing similar results and highlighting the safety of implanting bioprostheses in patients on chronic dialysis. Standards of valve selection have changed over time; it has long been believed that tissue valves undergo premature degeneration due to calcium metabolism derangements in patients with end-stage renal disease. Bleeding was the most common valve-related complication and represented a major drawback of mechanical valves. Two studies demonstrated a survival advantage in favour of mechanical prostheses. It can be concluded that surgeons should not hesitate to implant bioprostheses because singular valve decomposition would be uncommon in this patient population. Prosthesis selection should be based on the same criteria as those used for non-dialysis patients.
    Sultan Qaboos University medical journal 11/2013; 13(4):581-584.

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