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Outcomes in Patients With Chronic Renal Failure on Hemodialysis After Aortic Valve or Root Replacement

      The long-term survival and reoperation rate in chronic renal failure (CRF) on hemodialysis (HD) patients after aortic valve/root replacement (AVR/ARR) with a stentless bioprosthesis is unknown. From 1992–2015, 1941 patients underwent AVR/ARR with stentless valve for primary indications of aortic stenosis/insufficiency, root aneurysm, and acute type A aortic dissection, including 93 CRF-HD (64 new-onset postoperative HD, and 29 preoperative HD) and 1848 non-CRF-HD. Data was obtained from the STS database, retrospective chart review, administered surveys and national death index data. Compared to the non-CRF-HD group, the CRF-HD group had significantly higher incidence of diabetes mellitus (28 vs 18%), CAD (49 vs 38%), COPD (31 vs 16%), NYHA class IV (12 vs 4%), atrial fibrillation (24 vs 12%), and previous cardiac surgery (27 vs 16%). Postoperatively, CRF-HD group had a higher reoperation for bleeding (10 vs 4%), length of hospital stays (20 vs 7 days), and operative mortality (23 vs 2.3%), all p < 0.01. The odds ratio of CRF-HD for operative mortality was 8.97. The long-term survival was worse in CRF-HD group than that in non-CRF-HD group [8-year survival: 31% vs 70%, p < 0.0001]. The hazard ratio of CRF-HD for long-term mortality was 2.4. The 10-year cumulative reoperation rate for structural valve deterioration in the CRF-HD group was 6.0% vs 5.0% in the non-CRF-HD group, p = 0.74. Surgeons should consider poor short- and long-term outcomes of patients with high risk of being on dialysis when offering aortic valve/root replacement. Bioprosthesis could be a good option in this patient population.

      Graphical Abstract

      Keywords

      Abbreviations:

      ARR (aortic root replacement), AVR (aortic valve replacement), CRF (chronic renal failure), CRF-HD (chronic renal failure on hemodialysis), ESRD (end stage renal disease), HD (hemodialysis), SVD (structural valve deterioration), TAVR (transcatheter aortic valve replacement)
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      Linked Article

      • Commentary: Outcomes of Surgical Aortic Valve or Root Replacement in Patients on Hemodialysis: Lessons Learned and Remaining Challenges
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 3
        • Preview
          End-stage renal disease (ESRD) patients undergoing hemodialysis (HD) are at high-risk when undergoing surgical aortic valve replacement (SAVR). After SAVR, the cardiovascular disease and renal comorbidities in these HD patients increase the risk of 30-day mortality by up to 15-17%, approximately 40% at 3 years, and 60% at 5 years.1–3 Thus, it is essential to carefully assess preoperative comorbidities of each patient and to optimize prosthetic valve selection and surgical procedure. This will minimize the deleterious effect of cardiopulmonary bypass (CPB) and HD-associated postoperative morbidities and increase survival and quality of life.
        • Full-Text
        • PDF
      • Commentary: Stentless AVR in dialysis patients – another hand on the elephant
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 3
        • Preview
          There is a parable from the Indian subcontinent that a group of blind men approach an elephant and each of them has a dramatically different appreciation depending on which part of the elephant they are touching (tusk, ear, tail, trunk etc.). In the present report the authors make a valiant effort to understand the performance of the Medtronic Freestyle heterograft (Medtronic, Minneapolis MN) in the setting of Hemodialysis (HD) patients at their center and found excellent durability.1 Anecdotally, at our center we have also found the Freestyle valve a durable option for root replacement; and a recent review of Medicare recipients undergoing root replacement found excellent mid-term results.
        • Full-Text
        • PDF