Aortic stenosis (AS) is more prevalent, less predictable, and associated with a worse outcome among patients with chronic kidney disease (CKD). Patients with advanced or end-stage CKD have been excluded from clinical trials addressing management and intervention, resulting in an absence of prospective randomized data that can be used for management decisions in this population. This American Heart Association (AHA) scientific statement summarizes the characteristics of AS in the setting of concomitant CKD and information from noninvasive imaging, outlines special risks in this population, and reviews existing literature regarding clinical outcomes after surgical (SAVR) and transcatheter aortic valve replacement (TAVR) among patients with advanced CKD. The following are key points to remember:

1. AS in CKD results from progressive calcific degeneration that occurs earlier and with more rapid progression compared to people without CKD. Factors contributing to progression include the uremic milieu with retained toxins that promote vascular calcification, metabolic bone disease, chronic hypertension, volume overload, and hemodialysis-related high flow across the aortic valve.
2. Typical symptoms of AS including dyspnea and presyncope may overlap with other conditions among patients with advanced CKD; symptoms of AS in this population can be more subtle, including hypotension during dialysis, peridialysis atrial arrhythmias, and symptoms of extreme fatigue.
3. The echocardiographic assessment of AS severity is as problematic among patients with CKD as it is in other patients. In addition, the following factors should be considered:
   • Among patients with CKD undergoing hemodialysis, echocardiographic evaluation of AS severity should be performed the day after hemodialysis.
   • Because AS progresses more rapidly in the setting of CKD, follow-up echocardiography should be performed more often among asymptomatic patients with CKD and moderate or severe AS.
   • Several factors in CKD can lead to a low flow state, including left ventricular (LV) hypertrophy, fibrosis, or dysfunction; mitral regurgitation; and atrial fibrillation.
   • The presence of an arterial-venous fistula for hemodialysis results in a high-flow state that can alter the echo/Doppler assessment of AS hemodynamics. Acute fistula compression during the echo/Doppler exam can be used to reassess AS hemodynamics during temporary reduction in the transvalvular flow rate.
4. Imaging studies in addition to echo/Doppler can be useful.
   • Noncontrast computed tomography for aortic valve calcium burden can be used to adjudicate AS severity on echo/Doppler.
   • Invasive cardiac catheterization can be reasonable to confirm AS severity if diagnostic uncertainty persists after noninvasive imaging.
   • The risk of nephrogenic systemic fibrosis with group 2 gadolinium-based contrast agents (including gadobenate meglumine, gadobutrol, and gadoteridol) in patients with advanced CKD appears to be very low, potentially allowing its use in selected patients for the assessment of myocardial fibrosis.
5. Aortic valve replacement (AVR) is associated with a risk of acute kidney injury (AKI), with an associated increased risk of short-term and long-term mortality; pre-existing CKD is the most important risk factor for AKI after AVR. AKI risk reduction strategies during TAVR and SAVR include the following:
   • Ensure euvolemia at the time of TAVR or associated percutaneous coronary intervention (PCI).
   • Contrast-sparing techniques can be considered among patients with CKD undergoing staged PCI before TAVR.
   • Low-osmolar or iso-osmolar contrast is appropriate as part of a contrast-sparing strategy.
   • Transradial access is preferred in patients with high risk of AKI.
   • Concomitant nephrotoxins (aminoglycosides, nonsteroidal anti-inflammatory agents, vancomycin) should be discontinued and calcineurin inhibitor drug levels optimized before AVR.
6. The decision between a mechanical and bioprosthetic valve among patients with CKD undergoing SAVR should include weighing life expectancy, and the relative risks of lifelong anticoagulation and reintervention. Societal guidelines do not specify whether a tissue or mechanical valve should be used among patients with end-stage CKD.
7. The writing group recommends a multidisciplinary heart-kidney team approach for decisions between TAVR and SAVR among patients with CKD, including shared decision making with the patient.
8. The following should be considered in decisions regarding whether to pursue coronary revascularization before TAVR among patients with CKD:
   • Decisions should be made in collaboration with the multidisciplinary heart-kidney team, considering symptoms, the complexity of coronary disease, and the balance between pursuing complete revascularization and the risks of AKI and vascular complications.
   • The writing committee recommends a generally conservative approach to revascularization before TAVR.
   • Revascularization of left main disease may be reasonable.
9. Periprocedural management after AVR among patients with advanced CKD should include the following:
   • Hemodynamic and volume management.
   • Electrolyte management.
   • Avoiding contrast-induced AKI.
   • Consideration of periprocedural renal replacement options, including continuous dialysis modalities in the setting of tenuous hemodynamics.
   • Individualizing periprocedural anticoagulation and antiplatelet management.
10. Patients with CKD, and especially those undergoing dialysis, are at high risk for accelerated structural valve deterioration of a bioprosthesis. After AVR, patients require life-long follow-up with a cardiologist.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation

Keywords: Acute Kidney Injury, Anticoagulants, Aortic Valve Stenosis, Atrial Fibrillation, Bioprosthesis, Cardiac Catheterization, Cardiac Surgical Procedures, Contrast Media, Coronary Artery Disease, Diagnostic Imaging, Dialysis, Dyspnea, Echocardiography, Electrolytes, Fistula, Gadolinium, Heart Valve Diseases, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation, Hemodynamics, Hypertension, Hypertrophy, Left Ventricular, Hypotension, Mitral Valve Insufficiency, Percutaneous Coronary Intervention, Renal Dialysis, Renal Insufficiency, Renal Insufficiency, Chronic, Risk Factors, Secondary Prevention, Syncope, Tomography, Transcatheter Aortic Valve Replacement, Vascular Calcification

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