Valvular Heart Disease
Impact of Renal Dysfunction on Results of Transcatheter Aortic Valve Replacement Outcomes in a Large Multicenter Cohort

https://doi.org/10.1016/j.amjcard.2016.08.082Get rights and content

Patients with advanced chronic renal dysfunction were excluded from randomized trials of transcatheter aortic valve replacement (TAVR). The potential impact of chronic renal disease on TAVR prognosis is not fully understood. We aim to evaluate outcomes within a large cohort of patients who underwent TAVR distinguished by renal function. Baseline characteristics, procedural data, and clinical follow-up findings were collected from 10 high-volume TAVR centers in Europe, Israel, and Japan. Data were analyzed according to renal function. Patients (n = 1,204) were divided into 4 groups according to pre-TAVR-estimated glomerular filtration rate (eGFR): group I (eGFR >60), n = 288 (female 45%), group II (eGFR 31 to 60), n = 452 (female 61%), group III (eGFR ≤30), n = 398 (female 61%), and group IV (dialysis), n = 66 (female 31%). Mean Society of Thoracic Surgeons score was higher in patients with lower preprocedural eGFR. All-cause mortality at 1 year was higher in patients with lower eGFR (9.0%, 12.1%, 24.3%, and 24.2% for group I, II, III, and IV, respectively, p <0.001). Multivariate analysis demonstrated that eGFR ≤30, but not eGFR 31 to 60, was associated with increased risk of death (odds ratio 3), bleeding (odds ratio 5.2), and device implantation failure (hazard ratio 2.28). For each 10 ml/min decrease in eGFR, there was an associated relative increase in the risk of death (35%; p <0.001), cardiovascular death (14%; p = 0.018), major bleeding 35% (p <0.001), and transcatheter valve failure (16%; p = 0.007). Renal dysfunction was not associated with stroke or need for pacemaker implantation. In conclusion, among patients who underwent TAVR, baseline renal dysfunction is an important independent predictor of morbidity and mortality.

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Methods

A total of 1,204 consecutive patients with severe symptomatic AS who underwent TAVR from 2006 to 2015 with and without CKD were enrolled from 10 centers in Europe (Ferrarotto Hospital, Catania, Italy; Inselspital University Hospital, Bern, Switzerland; Institute Cardiovasculaire Paris Sud, Massy, France; Galway University Hospital, Galway Ireland; CHRU, Lille, France; University Hospital, Antwerp, Belgium; Bonn University Hospital, Bonn, Germany), Japan (Keio University Hospital, Keio), and

Results

Of the 1,204 patients, 288 were included in group I (eGFR >60 ml/min), 458 in group II (eGFR 31 to 60 ml/min), 452 in group III (eGFR ≤30 ml/min), and 66 in group IV (dialysis). Baseline characteristics of the study population according to CKD severity are listed in Table 1. Mean age increased with decreasing eGFR in patients who did not undergo dialysis, whereas patients in the dialysis group were the youngest (p <0.001). Mean STS score increased with decreasing eGFR (p <0.001). Baseline

Discussion

In this large multicenter analysis of patients who underwent TAVR for the treatment of severe symptomatic AS, renal dysfunction was associated with poor clinical outcomes. All-cause and cardiovascular mortality rates during the follow-up period increased with decreasing renal function. Importantly, a eGFR ≤30 ml/min was identified as an independent predictor for all-cause and cardiovascular mortality.

There is a broad agreement that TAVR outcomes are negatively influenced by advanced and

Disclosures

The authors have no conflicts of interest to disclose.

References (30)

Cited by (33)

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    Gargiulo et al. in their meta-analysis of 4992 patients who underwent TAVR found that patients with CKD 4 and 5 had worse 1-year all-cause mortality compared to patients with CKD 1 and 2 (OR 2.56; 95% CI 1.54–4.24; p = 0.0003). [40] Likewise, Codner et al. in their observational study of 1204 patients managed with TAVR found that every 10 ml/min decrease in eGFR was associated with a 19% increase in the risk of death (p < 0.001). [41] Several pathophysiologic mechanisms can explain the association of CKD with increased late all-cause mortality after MC.

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Drs Codner and Levi contributed equally to this article.

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