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92 Transcatheter Aortic Valve Implantation in Patients with Pre-existing Chronic Kidney Disease
  1. Mohammed Shamim Rahman1,
  2. Rajan Sharma2,
  3. Stephen JD Brecker2
  1. 1Imperial College London
  2. 2Department of Cardiology and Cardiothoracic Surgery, St George’s Hospital

Abstract

Introduction Transcatheter aortic valve implantation (TAVI) for symptomatic severe aortic stenosis is being increasingly undertaken in a more complex cohort of patients with multiple co-morbidities. Whilst it is a safe alternative to surgical aortic valve replacement in the high-risk population, these co-morbidities are often excluded from large trials. We sought to investigate the effect of chronic kidney disease (CKD) on morbidity and mortality following TAVI including patients on haemodialysis.

Methods We performed a post hoc analysis of a prospectively collected registry of all patients undergoing TAVI at our centre between 2008–12. Patients were grouped into a ‘CKD’ or a ‘No-CKD’ group (with CKD defined as patients with a baseline estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2). Patients requiring prior haemodialysis were included in the mortality and morbidity analysis but excluded from acute kidney injury (AKI) analysis. AKI was defined as set out in the recently updated Valve Academic Research Consortium (VARC-2) criteria. The TAVI procedure was performed using Medtronic CoreValve and Edward LifeSciences Sapien valves and implanted using the femoral (percutaneous and surgical cut-down), axillary, subclavian, transapical and transaortic routes.

Results 118 consecutive patients underwent TAVI with 63 considered to have significant pre-existing ‘CKD’ whilst 55 did not (‘No-CKD’). 4 patients required either chronic or acute renal replacement therapy (RRT) prior to the procedure. The mean age of the population was 81.3 ± 7.7 years (mean±SD), 57.6% were males, 22.0% diabetic and the mean Logistic EuroSCORE was 20.9 ± 14.9%. The baseline eGFR was 46.8 ± 8.7 and 77.9 ± 16.5 µmol/L in the CKD and No-CKD groups respectively. Other than renal parameters, no significant baseline differences existed between the two groups. TAVI implantation predominantly involved the Medtronic CoreValve (90%) and the percutaneous transfemoral route (76%). CKD patients received less contrast than No-CKD patients (151.6 ± 62.4 vs. 195.0 ± 56.8 mL, p < 0.001). Following TAVI, in CKD and No-CKD patients respectively; AKI occurred in 23.7% and 14.5% (p = 0.455) and RRT was necessary in 8.5% and 3.6% (relative risk [95% CI] = 2.33 [0.47–11.5], p = 0.440); 30-day mortality rates were 6.3% and 1.8% (p = 0.370) and 1-year mortality rates were 17.5% and 18.2% (p = 0.919). Patients who developed AKI had a significantly increased risk of 30-day (12.5% vs. 1.1%, p = 0.029) mortality. We found the presence of diabetes (odds ratio (OR) [95% CI] = 4.58 [1.58–13.3], p = 0.005) and elevated baseline serum creatinine (OR [95% CI] = 1.02 [1.00–1.03], p = 0.026) to independently predict AKI by multivariate analysis.

Conclusions TAVI is a safe, acceptable treatment for patients with pre-existing CKD, however caution must be exercised, particularly in patients with pre-existing diabetes mellitus and elevated pre-operative serum creatinine levels as this confers a greater risk of AKI development.

  • TAVI
  • AKI
  • CKD

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