Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients’ demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p <0.05) and AF (adjusted OR 2.42; 95% CI 1.3 to 4.4 p <0.05) were independently associated with mortality in patients with CKD. The most common comorbidities observed in patients with ESKD undergoing TAVI were heart failure, chronic lung disease, AF, MS, and pulmonary hypertension. An association between MS and increased mortality was observed (adjusted OR 2.01; 95 CI 0.93 to 2.02, p = 0.09) in patients with ESKD, but was not statistically significant. In conclusion, in patients with CKD undergoing TAVI, AF and MS were independently associated with increased mortality.
Patients with chronic kidney disease (CKD) are at a higher risk of developing aortic stenosis (AS), and have associated worse clinical outcomes. Similarly, AS is the most common valve abnormality seen in end-stage kidney disease (ESKD), and surgical aortic valve replacements in these individuals are associated with significant 1-year mortality. Furthermore, patients with CKD and ESKD often have multiple co-morbidities that may prohibit surgical intervention entirely or present a high surgical risk. Transcatheter aortic valve implantation (TAVI) has emerged as an important alternative intervention for select patients with severe symptomatic AS; however, less is known regarding clinical outcomes in patients with CKD or ESKD undergoing TAVI. At least 1 multicenter study has demonstrated worsening clinical outcomes as renal function decreases with regard to mortality in patients with TAVI. Even less is known regarding outcomes in patients with ESKD, as these patients were excluded from several previous large-scale clinical trials. In a recent analysis of the Transcatheter Valve Therapies registry, Szerlip et al observed a higher risk of in-hospital mortality in patients with ESKD who underwent TAVI. Indeed, TAVI is generally considered a higher risk intervention in patients with kidney disease. More data regarding the risk stratification of these patients is needed to guide real-world decision making. In this brief report, we aim to describe important baseline characteristics and outcome trends in patients with CKD and ESKD who underwent TAVI from a large database.
Methods
We analyzed data from the Mount Sinai Data Warehouse, which is an extensive urban health system that contains more than 20 data sources and more than 2 million patients within the Mount Sinai Health System electronic medical records from January 1, 2008, to December 31, 2018, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We identified patients undergoing TAVI using the principal diagnosis including the ICD-9-CM procedure codes 350.5 or 350.6. For CKD, patients were identified by ICD-9-CM codes 585.1, 585.2, 585.3, 585.4, 585.5, and 585.9. Finally, patients with ESKD were identified by the diagnosis code for long-term dialysis (585.6), or the procedure code for hemodialysis (39.95). Demographics, conventional cardiovascular risk factors, all co-morbidities, socioeconomics, medical management, and in-hospital outcomes were evaluated. Multivariable logistic regression modeling was performed to determine predictors associated with in-hospital mortality of TAVI in patients with CKD and ESKD. Patient demographics were compared, and significant morbidity and mortality outcomes were noted.
Results
First, we identified 643 subjects with CKD who underwent TAVI from 2011 to 2019 ( Table 1 ). The overall mortality was 5.1% for this group of patients. The majority of patients were White (67%), and 8% were Black. Notably, the frequency of common co-morbidities including hypertension, diabetes, hyperlipidemia, and obesity was relatively low at <1% for each comorbidity. The most frequently observed comorbidities were heart failure, mitral stenosis (MS), atrial fibrillation (AF), pulmonary hypertension, and chronic obstructive pulmonary disease. After multivariable analysis, we observed an independent association between both MS (adjusted odds ratio [OR] 3.92; 95% confidence interval [CI] 1.09 to 11.1, p <0.05) and AF (adjusted OR 2.42; 95% CI 1.3 to 4.4, p <0.05) and mortality. Second, we identified 84 subjects with ESKD who underwent TAVI from 2011 to 2019 ( Table 2 ). The overall mortality rate for patients with ESKD undergoing TAVI was more than 2 times higher than the CKD cohort at 11.9%. Similar to the CKD group, most patients were White (49%), and 17% were Black. Similar to the CKD group, the frequency of common co-morbidities, including hypertension, diabetes, hyperlipidemia, and obesity, was relatively low at <3% for all. The most common co-morbidities observed were heart failure, MS, chronic obstructive pulmonary disease, AF, and pulmonary hypertension. Finally, in patients with ESKD, there were no statistically significant mortality associations observed, including between MS (adjusted OR 2.01; 95 CI 0.93 to 2.02, p = 0.09) and mortality.
| Characteristics | Frequency |
|---|---|
| Men | 375 (58%) |
| White | 432 (67%) |
| Black | 52 (8%) |
| Asian | 3 (0.5%) |
| Prior percutaneous coronary intervention | 135 (21.0%) |
| Hypertension | 4 (0.6%) |
| Type 2 diabetes mellitus | 2 (0.3%) |
| Hyperlipidemia | 5 (0.8%) |
| Permanent pacemaker | 219 (34%) |
| Automatic implantable cardioverter-defibrillator | 63 (9.8%) |
| Heart failure | 609 (95%) |
| Obesity | 3 (0.5%) |
| Aortic regurgitation | 70 (11%) |
| Pulmonary hypertension | 174 (27%) |
| Cardiogenic shock | 7 (1%) |
| Cardiac arrest | 12 (2%) |
| Coronary artery bypass graft | 11 (1.7%) |
| Liver disease | 1 (0.2%) |
| Chronic obstructive pulmonary disease | 166 (26%) |
| Arrhythmias | |
| Atrial fibrillation | 224 (35%) |
| Ventricular arrhythmia | 36 (5.6%) |
| Ischemic stroke | 32 (5.0%) |
| Left bundle branch block | 144 (22%) |
| Right bundle branch block | 68 (11%) |
| Mitral regurgitation | 5 (0.8%) |
| Mitral stenosis | 17 (2.6%) |
| Malignant hypertension | 2 (0.3%) |
| Death | 33 (5%) |
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