Longitudinal Hemodynamics of Aortic Bioprosthetic Valve in Hemodialysis Patients

Published:September 08, 2021DOI:
      We examined the hemodynamic profile of bioprosthetic aortic valves in patients on hemodialysis (HD), longitudinally, and assess the incidence of adverse changes detected by echocardiography. Of 1,146 consecutive patients with severe aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR), 148 patients had end-stage renal disease requiring HD. Each patient on HD was matched one-to-one with a non-HD patient on the basis of propensity scores. The mean follow-up period was 3.3 years for the HD group and 5.9 years for the non-HD group. Follow-up information was available for 95.2%. Postoperative trends of valve hemodynamics derived from linear mixed-effect models showed significant group vs time interactions between the two groups. Stable hemodynamics was consistently observed in the non-HD group, whereas the HD group showed a decrease of -0.06 cm2/y (95% confidence interval (CI), -0.10 to -0.02) in effective orifice area, an increase of 0.8 mm Hg/year (95% CI, 0.4–1.1) in mean pressure gradient, and an increase of 0.08 m/s/year (95%CI, 0.02–0.13) in peak velocity. Cumulative incidence function of SVD more than stage 2 was significantly higher in the HD group (13.1% vs 3.1% at 5 years, Gray test p = 0.01). In a multivariable Fine-Gray analysis, diabetes was independently associated with SVD more than stage 2 in the HD group (subhazard ratio, 1.91; 95% CI, 1.25–2.89; p = 0.02). Survival free-from stenotic-type SVD was significantly lower in HD patients undergoing bioprosthetic AVR. Diabetes was independently associated with postoperative stenotic-type SVD in HD patients.



      AVR (aortic valve replacement), CI (confidence interval), CIF (Cumulative incidence function), EF (ejection fraction), EOA (effective orifice area), HD (hemodialysis), LV (left ventricular), mPG (mean aortic valve pressure gradient), NF-κB (nuclear factor kappa B), OPG (osteoprotegerin), RANKL (receptor activator of nuclear factor kappa B ligand), SVD (structural valve deterioration)
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      Linked Article

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          Valvular heart disease is particularly prevalent in the hemodialysis population, affecting 19.1% of end-stage renal disease (ESRD) patients, most commonly involving the aortic valve, and usually presenting as aortic stenosis.1 Valve selection in this population is particularly challenging. Mechanical valves are less vulnerable to the accelerated structural valve deterioration (SVD) observed in the bioprostheses of ESRD patients and were, in fact, the recommendation of the 1998 American College of Cardiology and/or American Heart Association Guidelines.
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          In the present study the authors retrospectively evaluated the longitudinal hemodynamic changes of bioprosthetic aortic valves implanted in hemodialysis patients in an effort to document the frequency of structural valvular deterioration (SVD), as detected by echocardiography.1 When compared to propensity matched non-HD patients they discovered early onset and accelerated progression of SVD as evidenced by significant per annum decrements in effective orifice area and increases in mean pressure gradient and peak velocity that started as early as2 years post implant.
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