A Meta-Analysis of Clinical Outcomes of Transcatheter Aortic Valve Replacement in Patients with End-Stage Renal Disease

Abstract

ABSTRACT Background: End-stage renal disease (ESRD) is associated with an increased incidence of severe aortic stenosis (AS). For these patients the usual care has been surgical aortic valve replacement (SAVR). ESRD patients are at increased surgical risk. Trans-aortic valve replacement (TAVR) may be an alternative to SAVR for these patients. However, TAVR trials have excluded patients with ESRD. Methods: MEDLINE, OMBASE and Cochrane databases were queried for relevant studies. A meta-analysis was performed on the selected studies. Primary outcome was early all-cause mortality; secondary outcomes included 1-year mortality, bleeding, neurological deficits, vascular complications, pacemaker requirement, and myocardial infarction. Results: A total of 16 studies included 3,499 patients. Most patients were high risk as demonstrated by Society of Thoracic Surgeons (STS) scores > 10 in most studies. Post-TAVR early and 1-year mortality were 10% (95%CI: 7.8–10.5%) and 33% (95%CI: 24.1–36.8%) respectively. Most common post-procedure complications were bleeding 17% (95%CI: 14.8–20.8%), pacemaker implant 14% (95%CI: 11.6–17.5%) and vascular complications 7% (95%CI: 4.3–9.9%). Neurological deficits and myocardial infarction were less common both at 1.2% (95%CI: 0.4–2.4%, 0.3–2.5% respectively). Three studies with 2,545 patients compared TAVR versus SAVR, there was no difference in early mortality (~ 10%, RR:1.0, 95%CI 0.60–1.64, p = 0.9). TAVR was associated with decreased risk of vascular complications (RR:0.58 95%CI: 0.3–0.8, p = 0.03). Conclusions: These results suggest that TAVR outcomes in ESRD patients are comparable to those patients considered extreme surgical risk. Compared to SAVR, there was no difference in early mortality, but fewer vascular complications. As the ESRD population continues to grow, future prospective studies should focus on this particular patient population.