Eastern Cardiothoracic Surgical Society

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Patients with chronic kidney disease undergoing aortic valve replacement for aortic stenosis have improved renal outcomes after TAVR compared to SAVR
Meghan O. Kelly, MD, Nathan Lohner, BS, Nadia H. Bakir, BS, Robert M. MacGregor, Joshua L. Manghelli, DO, Daniel I. Carter, BS, Lindsey R. Melby, Richard Schuessler, PhD, Ralph J. Damiano, MD, Spencer J. Melby, MD.
Washington University in St. Louis, St. Louis, MO, USA.

Background: Transcatheter aortic valve  replacement(TAVR) is considered  a  lower-risk alternative to surgical aortic valve replacement(SAVR), but  outcomes in patients with  chronic kidney disease(CKD) are not well defined.  We sought to compare outcomes of CKD patients undergoing TAVR vs.  SAVR. 
 Methods: Data was prospectively gathered and  retrospectively reviewed  for  652  consecutive  patients  undergoing SAVR (n=285) or TAVR (n=367) for aortic stenosis at a single institution from 2010 to 2017. Preoperative glomerular filtration rate (GFR) was used to determine patients with  baseline  CKD (GFR <60).  Propensity score analysis yielding 144 patients in each group  was done with a logistic model with nearest neighbor 1:1 matching and a 0.1 caliper algorithm to compare outcomes in those who had TAVR vs. SAVR.
Results: CKD  patients  who underwent TAVR were  older  with  more  comorbidities compared to those who had SAVR(Table).  Propensity score analyses revealed similar 30-day mortality  rates between  groups.  However, postoperative atrial fibrillation (12% vs. 34%; p < .01), pneumonia (0% vs. 9%; p <.01), and reoperation  for  bleeding (1% vs. 5%; p=.07) were higher in SAVR patients.  Acute renal failure (1% vs. 6%; p=.02) was worse in SAVR patients. More SAVR patients needed postoperative hemodialysis, but this was not significant (0% vs. 3%, p=.12). Five-year survival, however, was better in SAVR patients (11/144, 8% vs. 39/144, 27%, p =.006).
Conclusions: TAVR patients had  fewer postoperative  complications including better renal protection than SAVR, however, SAVR was beneficial for longer-term survival.  TAVR should be considered in patients with underlying kidney disease  to preserve renal function, but long-term survival may be better with SAVR.
Table 1.

Preoperative VariablesPostoperative Variables
Unmatched DataMatched DataMatched Data
VariableTAVR
n=367
SAVR
n=285
P-ValueTAVR
n=144
SAVR
n=144
P-ValueVariableTAVR
n=144
SAVR
n=144
P-Value
Age (years)8476<0.0181810.6130-day Mortality (%)4 (3)7 (5)0.54
BMI28.029.7<0.0129.028.70.91Atrial Fibrillation (%)17 (12)49 (34)<0.01
Preoperative GFR4549<0.0148470.92Postoperative GFR4542<0.01
Gender, Female (%)184 (50)149 (52)0.5981 (56)75 (52)0.48Renal Failure (%)1 (1)9 (6)0.02
Race, African American (%)19 (5)10 (4)0.345 (3)4 (3)1.00Dialysis (%)0 (0)4 (3)0.12
Hypertension (%)356 (97)259 (91)<0.01136 (94)132 (92)0.49Rebleed (%)1 (1)7 (5)0.07
Diabetes (%)166 (45)117 (41)0.2960 (42)61 (42)0.91Pneumonia (%)0 (0)13 (9)<0.01
COPD (%)203 (55)101 (35)<0.0157 (40)69 (48)0.15Stroke (%)1 (1)4 (3)0.37
Dyslipidemia (%)332 (90)241 (85)0.03128 (89)123 (85)0.38Sepsis (%)0 (0)3 (2)0.25


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