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Advanced Chronic Kidney Disease in Patients Undergoing Transcatheter Aortic Valve Implantation: Insights on Clinical Outcomes and Prognostic Markers From a Large Cohort of Patients
Study Questions:
What are the effects of advanced chronic kidney disease (CKD) on early and late outcomes after transcatheter aortic valve implantation (TAVI), and the predictive factors of poorer outcomes in such patients?
Methods:
This was a multicenter study including a total of 2,075 consecutive patients who had undergone TAVI. Patients were grouped according to the estimated glomerular filtration rate as follows: CKD stage 1-2 (≥60 ml/min/1.73 m2; n = 950), stage 3 (30–59 ml/min/1.73 m2; n = 924), stage 4 (15–29 ml/min/1.73 m2; n = 134), and stage 5 (<15 ml/min/1.73 m2 or dialysis; n = 67). Clinical outcomes were evaluated at 30 days and at follow-up (median of 15 [6–29] months) and defined according to the VARC criteria.
Results:
Advanced CKD (stage 4–5) was an independent predictor of 30-day major/life-threatening bleeding (p = 0.001) and mortality (p = 0.027), and late overall, cardiovascular, and noncardiovascular mortality (p < 0.01 for all). Pre-existing atrial fibrillation (hazard ratio [HR], 2.29; 95% confidence interval [CI], 1.47–3.58; p = 0.001) and dialysis therapy (HR, 1.86; 95% CI, 1.17–2.97; p = 0.009) were the predictors of mortality in advanced CKD patients, with a mortality rate as high as 71% at 1-year follow-up in those patients with these two factors. Advanced CKD patients who had survived at 1-year follow-up exhibited both a significant improvement in New York Heart Association class (p < 0.001) and no deterioration in valve hemodynamics (p = nonsignificant for changes in mean gradient and valve area over time).
Conclusions:
The authors concluded that advanced CKD was associated with a higher rate of early and late mortality and bleeding events following TAVI.
Perspective:
This study reports that advanced CKD in patients undergoing TAVI determines a higher risk for early and mid-term cardiovascular and noncardiovascular mortality. The occurrence of severe bleeding events played an important role in early and late deadly events, and the use of antithrombotic therapy overtreatment, especially dual antiplatelet therapy and/or the combination of warfarin with antiplatelet agents, should be re-evaluated in such patients. Among advanced CKD patients, those with either atrial fibrillation or dialysis therapy were at the highest risk, and in particular, the combination of these two factors led to an unacceptable mortality rate within the months following the TAVI procedure. These data may help improve the clinical decision-making process and appropriate selection for therapy in this challenging group of patients.
Keywords: Renal Dialysis, Follow-Up Studies, Platelet Aggregation Inhibitors, Warfarin, Glomerular Filtration Rate, Fibrinolytic Agents, Confidence Intervals, Creatinine, Hemodynamics, Renal Insufficiency, Chronic
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