Transcatheter Aortic Valve Replacement: Does Kidney Function Affect Outcome?

doi:10.1016/j.athoracsur.2013.04.035

The Annals of Thoracic Surgery

Volume 96, Issue 2, August 2013, Pages 507-512

https://doi.org/10.1016/j.athoracsur.2013.04.035 Get rights and content

Background

Chronic kidney disease is a significant risk factor for mortality as well as acute kidney injury in cardiac surgery. The impact of contrast agent application on outcome is not well described in patients undergoing transcatheter aortic valve implantation.

Methods

We analyzed data of 270 patients who underwent transcatheter aortic valve implantation (TAVI) between September 2008 and March 2012. Acute kidney injury was defined according to modified risk, injury, failure, loss and end-stage renal failure criteria. Patients on chronic hemodialysis were analyzed separately (n = 15). In 129 (47.8%) patients chronic kidney disease was apparent preoperatively. On average, 83.7 (± 32.4) mL of contrast agent were used per patient.

Results

Postoperatively, 41 patients (15.2%) developed acute kidney injury. In 19 patients (7.1%) transient renal replacement therapy was necessary; no chronic hemodialysis was required. Thirty-day-mortality did not differ between patients with or without chronic kidney disease (7.0% vs 7.1%, p = 0.97). Additionally, chronic kidney disease had no influence on the incidence of postoperative acute kidney injury (12.8% vs 20.2%, p = 0.07) or postoperative hemodialysis (5.0% vs 10.5%, p = 0.08). No correlation between the amount of contrast agent applied and the incidence of acute kidney injury could be verified (p = 0.57).

Conclusions

Preoperative chronic kidney disease does not increase the risk of mortality and acute kidney injury after transcatheter aortic valve implantation. Acute kidney injury after TAVI is associated with an elevated risk of mortality. The amount of contrast agent applied intra-procedurally does not affect the risk of acute kidney injury.

Section snippets

Patients

Between September 2008 and March 2012 a total of 270 patients underwent transapical transcatheter aortic valve implantation at our center. Preoperatively, all patients were evaluated for either transcatheter valve implantation or conventional aortic valve replacement by our heart team discussing their EuroSCORE, STS score, frailty by clinical presentation, and comorbidities. We prospectively collected demographic, perioperative, and postoperative clinical and paraclinical data to our database.

Patients

Mean age of our patients was 81.6 years, with 55.6% female patients and mean body mass index of 25.9 kg/m². Mean logistic EuroSCORE was 33.5% ± 18.1%; mean STS score was 14.0% ± 13.0%. Almost half of all patients (n = 122, 45.5%) received cardiac surgery (n = 65, 24.2%) or percutaneous coronary intervention (n = 57, 21.3%) prior to aortic valve operation; mean left ventricular ejection fraction was slightly impaired (LVEF = 0.56 ± 0.13). Further major risk factors were concomitant coronary

Comment

Acute kidney injury after conventional cardiac surgery is associated with significantly increased short- and long-term mortality 4, 18, 19, 20, 21. Our data confirm these findings for patients undergoing transcatheter aortic valve implantation. In addition, we differentiated survival according to the stage of AKI proposed by the VARC consortium [16]. As expected, our patients with AKI stage 1 and 2 showed similar survival rates to patients without AKI. But in patients with AKI stage 3 requiring

References (29)

A. Shaw
Update on acute kidney injury after cardiac surgery
J Thorac Cardiovasc Surg
(2012)
K.L. Greason et al.
Safety of same-day coronary angiography in patients undergoing elective aortic valve replacement
Ann Thorac Surg
(2011)
G.M. Chertow et al.
Independent association between acute renal failure and mortality following cardiac surgery
Am J Med
(1998)
J.M. Sinning et al.
Renal function as predictor of mortality in patients after percutaneous transcatheter aortic valve implantation
JACC Cardiovasc Interv
(2010)
J.T. Strauch et al.
Minimally invasive transapical aortic valve implantation and the risk of acute kidney injury
Ann Thorac Surg
(2010)
Y. Elhmidi et al.
Incidence and predictors of acute kidney injury in patients undergoing transcatheter aortic valve implantation
Am Heart J
(2011)
G.M. Chertow et al.
Acute kidney injury, mortality, length of stay, and costs in hospitalized patients
J Am Soc Nephrol
(2005)
K. Karkouti et al.
Acute kidney injury after cardiac surgery: focus on modifiable risk factors
Circulation
(2009)
R. Bagur et al.
Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement
Eur Heart J
(2010)
M. Wessely et al.
Chronic kidney disease is not associated with a higher risk for mortality or acute kidney injury in transcatheter aortic valve implantation
Nephrol Dial Transplant
(2012)

M. Thomas et al.

One-year outcomes of cohort 1 in the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry: the European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve

Circulation

(2011)

R.J. Nuis et al.

Frequency, determinants, and prognostic effects of acute kidney injury and red blood cell transfusion in patients undergoing transcatheter aortic valve implantation

Catheter Cardiovasc Interv

(2011)

V.H. Thourani et al.

Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement

Ann Thorac Surg

(2011)

J. Turina et al.

Spontaneous course of aortic valve disease

Eur Heart J

(1987)

Cited by (43)

Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease
2019, Journal of the American College of Cardiology
Citation Excerpt :
During 1-year follow-up, it is apparent that patients on dialysis who survive the procedure have a higher rate of rehospitalization, limiting their overall improvement in quality of life. A recently published series (19) showed no difference in 30-day mortality in patients with ESRD, contrasting the findings in our study. It is likely that this study was not powered to show an association between ESRD and mortality due to their small sample size.
In patients with end-stage renal disease (ESRD), surgical aortic valve replacement is associated with higher early and late mortality, and adverse outcomes compared with patients without renal disease. Transcatheter aortic valve replacement (TAVR) offers another alternative, but there are limited reported outcomes.
The purpose of this study was to determine the outcomes of TAVR in patients with ESRD.
Among the first 72,631 patients with severe aortic stenosis (AS) treated with TAVR enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT (Transcatheter Valve Therapies) registry, 3,053 (4.2%) patients had ESRD and were compared with patients who were not on dialysis for demographics, risk factors, and outcomes.
Compared with the nondialysis patients, ESRD patients were younger (76 years vs. 83 years; p < 0.01) and had higher rates of comorbidities leading to a higher STS predicted risk of mortality (median 13.5% vs. 6.2%; p < 0.01). ESRD patients had a higher in-hospital mortality (5.1% vs. 3.4%; p < 0.01), although the observed to expected ratio was lower (0.32 vs. 0.44; p < 0.01). ESRD patients also had a similar rate of major vascular complications (4.5% vs. 4.6%; p = 0.86), but a higher rate of major bleeding (1.4% vs. 1.0%; p = 0.03). The 1-year mortality was significantly higher in dialysis patients (36.8% vs. 18.7%; p < 0.01).
Patients undergoing TAVR with ESRD are at higher risk and had higher in-hospital mortality and bleeding, but similar vascular complications, when compared with those who are not dialysis dependent. The 1-year survival raises concerns regarding diminished benefit in this population. TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis.
Impact of post-procedural hyperglycemia on acute kidney injury after transcatheter aortic valve implantation
2016, International Journal of Cardiology
Citation Excerpt :
We observed that post-procedural hyperglycemia was more frequent in patients with DM, CKD and higher logistic and standard EuroSCOREs; however, it remained an independent predictor of AKI even after adjustment for these variables (OR 2.0, p < 0.001). We also identified peri-procedural bleeding requiring transfusion, logistic EuroSCORE and body mass index as independent predictors of AKI after TAVI, supporting previous findings from other studies [4,7,31]. The development of hyperglycemia may have a negative impact on kidney function and therefore increase the renal toxicity of contrast agents.
Post-operative hyperglycemia, in individuals with and without diabetes, has been identified as a predictor of acute kidney injury (AKI) in patients following cardiac surgery. Whether or not this is also true for patients undergoing transcatheter aortic valve implantation (TAVI) is unknown.
To evaluate whether post-procedural glucose levels are associated with AKI after TAVI.
A total of 422 consecutive patients undergoing transfemoral TAVI were included in the analysis. For each patient, plasma glucose levels were assessed at hospital admission, 4 h after the procedure and daily during hospitalization. Post-procedural hyperglycemia was defined as 2 consecutive blood glucose readings ≥ 150 mg/dL in the 72-hour period following TAVI. AKI was defined according to the VARC consensus report regarding standardized endpoint definitions. Overall, 137 (32.5%) patients developed post-procedural hyperglycemia and 138 (33%) patients developed AKI. Hyperglycemia was associated with a 2-fold higher incidence of AKI than in patients without hyperglycemia (48% vs. 25%, p < 0.001). In-hospital mortality was higher in patients with hyperglycemia than in those without hyperglycemia (9.6% vs. 1.8%, p < 0.001). In-hospital mortality rate was also higher in patients who developed AKI (12.7% vs. 2.7%, p < 0.001). Patients with acute hyperglycemia that developed AKI had the highest in-hospital and long-term mortality rate (15% and 38%). Post-procedural hyperglycemia was an independent predictor of AKI.
Post-procedural hyperglycemia is associated with a higher incidence of AKI and mortality after TAVI. Randomized controlled trials are needed to determine whether meticulous post-procedural glycemic control following TAVI impacts upon clinical outcomes.
Impact of Preoperative Chronic Kidney Disease in 2,531 High-Risk and Inoperable Patients Undergoing Transcatheter Aortic Valve Replacement in the PARTNER Trial
2016, Annals of Thoracic Surgery
Citation Excerpt :
Not all studies have shown CKD as a significant independent predictor for mortality. Goebel and colleagues [16] showed that preoperative stage 3 or greater CKD did not increase the risk of mortality after TAVR in 129 patients at 30 days (7.0% versus 7.1%, p = 0.97). In addition, they noted that CKD had no influence on the incidence of AKI (12.8% versus 20.2%, p = 0.07) or postoperative dialysis (5.0% versus 10.5%, p = 0.08) [16].
Although preoperative renal dysfunction (RD) is associated with increased mortality and morbidity after surgical aortic valve replacement, its impact on clinical outcomes after transcatheter aortic valve replacement (TAVR) is less defined.
TAVR patients in the PARTNER (Placement of Aortic Transcatheter Valves) trial with a calculable glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease equation were included. Patients were divided into three groups: GFR >60 mL/min (none/mild RD), GFR 31 to 60 mL/min (moderate RD), and GFR ≤30 mL/min (severe RD). Operative characteristics and clinical outcomes were analyzed. Cox regression models were used to determine multivariable predictors of 1-year all-cause mortality.
A total of 2,531 inoperable or high surgical risk patients from the PARTNER trial and continued access registries had a calculable GFR level: 767 (30%) had normal renal function or mild RD, 1,473 (58%) had moderate RD, and 291 (12%) presented with severe RD. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for the cohort was 11.5%, and it was highest in those with severe RD (13.8%). Patients with severe RD were more often women with a higher prevalence of diabetes. Patients with severe RD had the highest incidence of 30-day and 1-year all-cause mortality and rehospitalization. The 30-day rate of death from any cause was 10.7% in the severe RD group versus 6.0% in the moderate and mild RD groups (p = 0.01). The 1-year rate of death from any cause was 34.4% in the severe RD group versus 21.5% in the moderate RD and 20.8% in the none/mild RD groups (adjusted hazard ratio [HR] 2.24, p < 0.0001 for severe versus none/mild; adjusted HR 1.14, p = 0.24 for severe versus moderate). Other significant predictors of 1-year all-cause mortality included lower body mass index, frailty, the transapical approach, a lower ejection fraction, oxygen-dependent chronic obstructive pulmonary disease, liver disease, and male sex.
Preoperative severe RD is a significant predictor for 1-year mortality in TAVR patients. Careful risk stratification by the heart team is required in patients with severe preprocedural RD.
Cardiovascular MRI with ferumoxytol
2016, Clinical Radiology
The practice of contrast-enhanced magnetic resonance angiography (CEMRA) has changed significantly in the span of a decade. Concerns regarding gadolinium (Gd)-associated nephrogenic systemic fibrosis in those with severely impaired renal function spurred developments in low-dose CEMRA and non-contrast MRA as well as efforts to seek alternative MR contrast agents. Originally developed for MR imaging use, ferumoxytol (an ultra-small superparamagnetic iron oxide nanoparticle), is currently approved by the US Food and Drug Administration for the treatment of iron deficiency anaemia in adults with renal disease. Since its clinical availability in 2009, there has been rising interest in the scientific and clinical use of ferumoxytol as an MR contrast agent. The unique physicochemical and pharmacokinetic properties of ferumoxytol, including its long intravascular half-life and high r₁ relaxivity, support a spectrum of MRI applications beyond the scope of Gd-based contrast agents. Moreover, whereas Gd is not found in biological systems, iron is essential for normal metabolism, and nutritional iron deficiency poses major public health challenges worldwide. Once the carbohydrate shell of ferumoxytol is degraded, the elemental iron at its core is incorporated into the reticuloendothelial system. These considerations position ferumoxytol as a potential game changer in the field of CEMRA and MRI. In this paper, we aim to summarise our experience with the cardiovascular applications of ferumoxytol and provide a brief synopsis of ongoing investigations on ferumoxytol-enhanced MR applications.
Positive blood pressure response may predict the recovery of renal function after transcatheter aortic valve implantation
2024, Blood Pressure Monitoring
Microcirculatory tissue oxygenation correlates with kidney function after transcatheter aortic valve implantation–Results from a prospective observational study
2023, Frontiers in Cardiovascular Medicine

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Original articleAdult cardiacTranscatheter Aortic Valve Replacement: Does Kidney Function Affect Outcome?

Background

Methods

Results

Conclusions

Section snippets

Patients

Patients

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

Am J Med

JACC Cardiovasc Interv

Ann Thorac Surg

Am Heart J

Acute kidney injury, mortality, length of stay, and costs in hospitalized patients

J Am Soc Nephrol

Acute kidney injury after cardiac surgery: focus on modifiable risk factors

Circulation

Acute kidney injury following transcatheter aortic valve implantation: predictive factors, prognostic value, and comparison with surgical aortic valve replacement

Eur Heart J

Chronic kidney disease is not associated with a higher risk for mortality or acute kidney injury in transcatheter aortic valve implantation

Nephrol Dial Transplant

One-year outcomes of cohort 1 in the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry: the European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve

Circulation

Frequency, determinants, and prognostic effects of acute kidney injury and red blood cell transfusion in patients undergoing transcatheter aortic valve implantation

Catheter Cardiovasc Interv

Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement

Ann Thorac Surg

Spontaneous course of aortic valve disease

Eur Heart J

Original article
Adult cardiac
Transcatheter Aortic Valve Replacement: Does Kidney Function Affect Outcome?