TAVR vs. SAVR in Chronic Kidney Disease
- Analysis from the PARTNER 2A trial and SAPIEN 3 registry shows comparable outcomes between newest generation TAVR (SAPIEN 3) and SAVR in patients with severe aortic stenosis and moderate to severe chronic kidney disease.
- Patients undergoing SAVR were more likely to develop acute kidney injury compared to TAVR; however, rates of hemodialysis at 5 years were similar.
- Valve durability was comparable between newest generation TAVR and SAVR. Overall rates of structural deterioraton and valve failure were low.
What are 5-year outcomes in patients with severe aortic stenosis and chronic kidney disease (CKD) undergoing transcatheter (TAVR) versus surgical aortic valve replacement (SAVR)?
Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 ml/min/m2) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory–adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed.
The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs. 68.0%; p = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs. 58.7%; p = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs. 10.3%; p < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (p < 0.05), but not for SAPIEN 3 TAVR.
In intermediate-risk patients with aortic stenosis and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.
This analysis from the PARTNER trial and SAPIEN 3 registry shows comparable outcomes between newest generation TAVR (SAPIEN 3) and SAVR in patients with severe aortic stenosis and moderate to severe CKD. Patients undergoing SAVR were more likely to develop AKI compared to TAVR; however, rates of hemodialysis at 5 years were similar. Valve durability was comparable with the newest generation TAVR and SAVR, and rates of structural deterioraton and failure were low. Data from the analysis provide important insights into treatment choices for this challenging subset of patients with severe aortic stenosis. Newest generation TAVR appears to have equivalent long-term outcomes when compared to SAVR.
Keywords: Acute Kidney Injury, Aortic Valve Stenosis, Bioprosthesis, Cardiac Surgical Procedures, Glomerular Filtration Rate, Heart Valve Diseases, Heart Valve Prosthesis, Kidney Diseases, Renal Dialysis, Renal Insufficiency, Chronic, Stroke, Transcatheter Aortic Valve Replacement
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