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Heart Valve Prosthesis Selection in Patients With End-Stage Renal Disease Requiring Dialysis: A Systematic Review and Meta-Analysis
Study Questions:
Using a meta-analysis of previously published studies, are there clinical data to support the use of a bioprosthesis versus a mechanical prosthesis among patients with end-stage renal disease (ESRD) on hemodialysis who undergo heart valve replacement?
Methods:
A meta-analysis was performed using studies published in English beginning in 1990; studies were included if they compared bioprostheses with mechanical prostheses in patients with ESRD on dialysis. Extracted summary estimates included the hazard ratio (HR) for death and the odds ratio (OR) for developing valve-related complications due to the use of bioprostheses versus mechanical prostheses.
Results:
Twelve studies published from 1997 to 2010 were included in this review, of which nine were used in the meta-analysis. No evidence of publication bias was detected. In these studies, the aortic valve was the most common valve replaced (4,339 of 6,350), although 11 of the 12 studies also included mitral or multiple valve replacements. No difference in survival was observed between valve types (bioprosthesis vs. mechanical prosthesis, HR, 1.3; 95% confidence interval (CI), 1.0-1.9; p = 0.09). However, valve replacement with a bioprosthesis was associated with fewer valve-related complications compared to a mechanical prosthesis (OR, 0.4; 95% CI, 0.2-0.7; p = 0.002).
Conclusions:
A meta-analysis of the published literature demonstrates no survival difference following valve replacement with either a bioprosthesis or a mechanical prosthesis in patients with ESRD on dialysis. Bioprosthetic valve replacement was associated with fewer valve-related complications. Although this meta-analysis cannot discriminate between the sites of valve implant, the authors concluded that the data can likely be extended to include at least aortic valve replacement.
Perspective:
In the past, it was believed that bioprosthetic valve replacement in patients with ESRD on hemodialysis was contraindicated because of concern for premature valve calcification and ensuing structural valve failure. However, observational studies have demonstrated that the prognosis for patients with ESRD who undergo valve replacement is so horrific that premature structural valve deterioration does not appear to be a pertinent concern. (For example, see Herzog, et al. Circulation 2002;105:1336-41; revealing an approximate 15% 5-year survival in this cohort.) This meta-analysis confirms that fears of higher mortality after bioprosthetic valve replacement are unfounded. Avoiding long-term Coumadin therapy among patients who typically require three-times weekly vascular access for hemodialysis likely contributes to fewer valve-related complications in association with a bioprosthesis.
Keywords: Renal Dialysis, Heart Valve Prosthesis
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