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Renal Function and Outcomes After TAVR
Study Questions:
What is the effect of transcatheter aortic valve replacement (TAVR) among patients with baseline renal impairment?
Methods:
This was a substudy of patients with baseline renal impairment (estimated glomerular filtration rate [eGFR] ≤60 ml/min) and paired baseline and 30-day measures of renal function undergoing TAVR in the PARTNER 1 trial, and continued access registries conducted in 25 centers in the United States and Canada. Patients were categorized with improved eGFR (30-day follow-up eGFR ≥10% higher than baseline pre-TAVR), worsened eGFR (≥10% lower), or no change in renal function (neither). Baseline characteristics, 30-day to 1-year all-cause mortality, and repeat hospitalization were compared. A Cox proportional hazard regression analysis was performed to determine predictors of 1-year all-cause mortality, and logistic regression models were used to determine the predictors of improvement in eGFR and of worsening in eGFR.
Results:
Of the 821 participants, 401 (48.8%) were women and the mean (standard deviation) age for participants with improved, unchanged, or worsening eGFR was 84.90 (6.91) years, 84.37 (7.13) years, and 85.39 (6.40) years, respectively. The eGFR was 60 ml/min or lower among 821 patients (72%), of whom 345 (42%) improved, 196 (24%) worsened, and 280 (34%) had no change at 30 days. There were no differences in baseline age, body mass index, diabetes, chronic obstructive pulmonary disease, coronary artery disease, peripheral arterial disease, hypertension, pulmonary hypertension, renal or liver disease, New York Heart Association class III/IV symptoms, transaortic gradient, left ventricular ejection fraction, or procedural characteristics. The group with improved eGFR had more women, nonsmokers, and a lower cardiac index. Those with worsening eGFR had a higher median Society of Thoracic Surgeons score and left ventricle mass. From 30 days to 1 year, those with improved eGFR had no difference in mortality or repeat hospitalization. Those with worsening eGFR had increased mortality (25.5% vs. 19.1%, p = 0.07), but no significant increases in repeat hospitalization or dialysis. Predictors of improved eGFR were being female (odds ratio [OR], 1.38; 95% confidence interval [CI], 1.03-1.85; p = 0.03), and nonsmoking status (OR, 1.49; 95% CI, 1.11-1.01; p = 0.01); predictors of worsening eGFR were baseline left ventricle mass (OR, 1.00; 95% CI, 1.00-1.01; p = 0.01), smoking (OR, 1.51; 95% CI, 1.06-2.14; p = 0.02), and age (OR, 1.03; 95% CI, 1.00-1.05; p = 0.05); and predictors of 1-year mortality were baseline left ventricular ejection fraction (OR, 0.98; 95% CI, 0.97-0.99; p = 0.003), baseline eGFR (OR, 0.98; 95% CI, 0.96-0.99; p < 0.001), and worsening eGFR versus no change in eGFR (OR, 1.51; 95% CI, 1.02-2.24; p = 0.04).
Conclusions:
The authors concluded that while improved eGFR did not improve 1-year outcomes, worsening eGFR was associated with increased mortality.
Perspective:
This study reports that decreased baseline eGFR was frequent among patients undergoing TAVR, and while the group with improved eGFR showed no differences in all-cause mortality or the need for repeat hospitalization, but did trend toward a lower need for dialysis, patients with worsening eGFR trended toward increased all-cause mortality. Adequate preprocedural hydration, minimizing the duration of rapid pacing and associated hypotension at time of the transcatheter valve deployment, and possibly using newer techniques such as the RenalGuard system and renal embolic protection devices may help avoid post-TAVR worsening of renal function and possibly improve outcomes.
Keywords: Embolic Protection Devices, Glomerular Filtration Rate, Heart Valve Diseases, Hypertension, Hypotension, Primary Prevention, Renal Dialysis, Renal Insufficiency, Smoking, Stroke Volume, Transcatheter Aortic Valve Replacement, Treatment Outcome
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