In-hospital outcomes of transcatheter versus surgical aortic valve replacement in end stage renal disease
Corresponding Author
Ahmad Alkhalil MD, MSc
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Correspondence Ahmad Alkhalil, MD, MSc, Rutgers University Hospitals, Newark, NJ, 185 South Orange Ave, Newark, NJ 07103. Email: [email protected]Search for more papers by this authorShervin Golbari MD
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Search for more papers by this authorDavid Song MD
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Search for more papers by this authorHarveen Lamba MD, MSc
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorAnas Fares MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorAmer Alaiti MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorSalil Deo MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorGuilherme F. Attizzani MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorHomam Ibrahim MD
Department of Medicine/Division of Cardiology, University of Utah, Salt Lake City, Utah
Search for more papers by this authorCarlos E. Ruiz MD, PhD
Department of Medicine/Division of Cardiology, Hackensack University Medical Center, Hackensack, New Jersey
Search for more papers by this authorCorresponding Author
Ahmad Alkhalil MD, MSc
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Correspondence Ahmad Alkhalil, MD, MSc, Rutgers University Hospitals, Newark, NJ, 185 South Orange Ave, Newark, NJ 07103. Email: [email protected]Search for more papers by this authorShervin Golbari MD
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Search for more papers by this authorDavid Song MD
Department of Medicine/Division of Cardiology, Rutgers University School of Medicine, Newark, New Jersey
Search for more papers by this authorHarveen Lamba MD, MSc
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorAnas Fares MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorAmer Alaiti MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorSalil Deo MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorGuilherme F. Attizzani MD
Department of Medicine/Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
Search for more papers by this authorHomam Ibrahim MD
Department of Medicine/Division of Cardiology, University of Utah, Salt Lake City, Utah
Search for more papers by this authorCarlos E. Ruiz MD, PhD
Department of Medicine/Division of Cardiology, Hackensack University Medical Center, Hackensack, New Jersey
Search for more papers by this authorAbstract
Background
Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) who are at intermediate and high risk for surgery. Commercial use of TAVR has expanded to patients with end stage renal disease (ESRD).
Objectives
Compare in-hospital outcomes of TAVR versus SAVR in ESRD patients requiring hemodialysis (HD).
Methods
ESRD patients on HD undergoing TAVR (n = 328) or SAVR (n = 697) between 2012 and 2014 were identified in the National Inpatient Sample (NIS). Propensity-score matching method was used to minimize selection bias. Baseline characteristics and in-hospital outcomes were compared.
Results
TAVR patients were older (75.3 vs. 61.6 years, P < 0.001) and had more comorbidities, including congestive heart failure (16.2% vs. 7.5%), diabetes mellitus (28.4% vs. 22.5%), chronic lung disease (27.7% vs. 20.4%), and peripheral vascular disease (35.1% vs. 21.2%). Propensity-score matching yielded 175 pairs of patients matched on 30 baseline covariates. Overall in-hospital mortality was high (9.9%) and similar between TAVR and SAVR (8% vs. 10.3%, P = 0.58). TAVR was associated with shorter length of stay (LOS) (8 vs. 14 days, P < 0.001), lower hospitalization cost ($276,448 vs. $364,280, P = 0.01), lower in-hospital complications (60.6% vs. 76%, P = 0.003), and higher rate of home discharge (31.4% vs. 17.7%, P = 0.004) compared with SAVR.
Conclusions
Regardless of treatment modality, patients with AS on HD have high in-hospital mortality. TAVR and SAVR have comparable in-hospital mortality in this population. However, TAVR is associated with shorter LOS, lower hospitalization costs, lower in-hospital complications, and higher rates of home discharge.
CONFLICT OF INTEREST
Dr. Attizzani is a consultant and serves as a proctor for Edwards Lifesciences and Medtronic, and is a consultant for St Jude Medical and Abbott Vascular. Dr. Ruiz is a consultant for St Jude Medical, Abbott Vascular, CardiacImplants, MitrAssist, Mitral Bridge and Tendyne. Drs. Alkhalil, Golbari, Song, Lamba, Fares, Alaiti, Deo, and Ibrahim have nothing to disclose.
Supporting Information
Additional Supporting Information may be found online in the supporting information tab for this article.
| Filename | Description |
|---|---|
| ccd27433-sup-0001-suppinfo01.tiff2.2 MB | Supporting Information Figure 1 |
| ccd27433-sup-0002-suppinfo02.docx13.6 KB | Supporting Information Table 1 |
| ccd27433-sup-0003-suppinfo03.docx22.2 KB | Supporting Information Table 2 |
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REFERENCES
- 1 Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363: 1597–1607.
- 2 Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK, Thourani VH, Tuzcu EM, Miller DC, Herrmann HC, Doshi D, Cohen DJ, Pichard AD, Kapadia S, Dewey T, Babaliaros V, Szeto WY, Williams MR, Kereiakes D, Zajarias A, Greason KL, Whisenant BK, Hodson RW, Moses JW, Trento A, Brown DL, Fearon WF, Pibarot P, Hahn RT, Jaber WA, Anderson WN, Alu MC, Webb JG. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med 2016; 374: 1609–1620.
- 3 Barbash IM, Finkelstein A, Barsheshet A, Segev A, Steinvil A, Assali A, Ben Gal Y, Vaknin Assa H, Fefer P, Sagie A, Guetta V, Kornowski R. Outcomes of patients at estimated low, intermediate, and high risk undergoing transcatheter aortic valve implantation for aortic stenosis. Am J Cardiol 2015; 116: 1916–1922.
- 4 Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364: 2187–2198.
- 5 Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller J Jr, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK; U.S. CoreValve Clinical Investigators. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014; 370: 1790–1798.
- 6 Meola M, Samoni S, Petrucci I. Clinical scenarios in chronic kidney disease: Vascular chronic diseases. Contrib Nephrol 2016; 188: 81–88.
- 7 Ibrahim H, Rao SV. Oral antiplatelet drugs in patients with chronic kidney disease (CKD): A review. J Thromb Thrombolysis 2017; 43: 519–527.
- 8 Umana E, Ahmed W, Alpert MA. Valvular and perivalvular abnormalities in end-stage renal disease. Am J Med Sci 2003; 325: 237–242.
- 9 Ureña P, Malergue MC, Goldfarb B, Prieur P, Guédon-Rapoud C, Pétrover M. Evolutive aortic stenosis in hemodialysis patients: Analysis of risk factors. Nephrologie 1999; 20: 217–225.
- 10 Guerraty MA, Chai B, Hsu JY, Ojo AO, Gao Y, Yang W, Keane MG, Budoff MJ, Mohler ER. Relation of aortic valve calcium to chronic kidney disease (from the Chronic Renal Insufficiency Cohort Study). Am J Cardiol 2015; 115: 1281–1286.
- 11 Kim D, Shim CY, Hong GR, Cho IJ, Chang HJ, Ha JW, Chung N. Effect of end-stage renal disease on rate of progression of aortic stenosis. Am J Cardiol 2016; 117: 1972–1977.
- 12 Kim IY, Kim MJ, Lee DW, Lee SB, Shin MJ, Rhee H, Yang BY, Song SH, Seong EY, Kwak IS. Cardiac valve calcification is associated with presence and severity of coronary artery disease in patients with pre-dialysis chronic kidney disease. Clin Exp Nephrol 2015; 19: 1090–1097.
- 13 Kobrin DM, McCarthy FH, Herrmann HC, Anwaruddin S, Kobrin S, Szeto WY, Bavaria JE, Groeneveld PW, Desai ND. Transcatheter and surgical aortic valve replacement in dialysis patients: A propensity-matched comparison. Ann Thorac Surg 2015; 100: 1230–1237.
- 14 HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP). 2012–2014. Rockville, MD: Agency for Healthcare Research and Quality. Available at: www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed August 22, 2017.
- 15ICD-9-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles. Centers for Medicare and Medicaid Services Website https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/Downloads/FY2012_Addenda.pdf. Updated October 1, 2011. Accessed August 22, 2017.
- 16 Bhise V, Kanade P, Shantha G, Balan P, Nguyen TC, Loyalka P, Kar B, Estrera A, Smalling RW, Dhoble A. Transcatheter and surgical aortic valve replacement in patients with end-stage renal disease. JACC 2017; 69: 1873–1881.
- 17 Sarnak MJ. Cardiovascular complications in chronic kidney disease. Am J Kidney Dis 2003; 41: S11–S17.
- 18 London GM, Pannier B, Marchais SJ, Guerin AP. Calcification of the aortic valve in the dialyzed patient. J Am Soc Nephrol 2000; 11: 778–783.
- 19 Edwards FH, Peterson ED, Coombs LP, DeLong ER, Jamieson WR, Shroyer ALW, Grover FL. Prediction of operative mortality after valve replacement surgery. J Am Coll Cardiol 2001; 37: 885–892.
- 20 Herzog CA, Ma JZ, Collins AJ. Long-term survival of dialysis patients in the United States with prosthetic heart valves: Should ACC/AHA practice guidelines on valve selection be modified? Circulation 2002; 105: 1336–1341.
- 21 Thourani VH, Chowdhury R, Gunter RL, Kilgo PD, Chen EP, Puskas JD, Halkos ME, Lattouf OM, Cooper WA, Guyton RA. The impact of specific preoperative organ dysfunction in patients undergoing aortic valve replacement. Ann Thorac Surg 2013; 95: 838–845.
- 22 Brinkman WT, Williams WH, Guyton RA, Jones EL, Craver JM. Valve replacement in patients on chronic renal dialysis: Implications for valve prosthesis selection. Ann Thorac Surg 2002; 74: 37–42; discussion 42.
- 23 Lucke JC, Samy RN, Atkins BZ, Silvestry SC, Douglas JM Jr, Schwab SJ, Wolfe WG, Glower DD. Results of valve replacement with mechanical and biological prostheses in chronic renal dialysis patients. Ann Thorac Surg 1997; 64: 129–132. discussion 132–133.
- 24 Horst M, Mehlhorn U, Hoerstrup SP, Suedkamp M, de Vivie ER. Cardiac surgery in patients with end-stage renal disease: 10-year experience. Ann Thorac Surg 2000; 69: 96–101.
- 25 Kaplon RJ, Cosgrove DM, Gillinov AM, Lytle BW, Blackstone EH, Smedira NG. Cardiac valve replacement in patients on dialysis: Influence of prosthesis on survival. Ann Thorac Surg 2000; 70: 438–441.
- 26 Codner P, Levi A, Gargiulo G, Praz F, Hayashida K, Watanabe Y, Mylotte D, Debry N, Barbanti M, Lefèvre T, Modine T, Bosmans J, Windecker S, Barbash I, Sinning J-M, Nickenig G, Barsheshet A, Kornowski R. Impact of renal dysfunction on results of transcatheter aortic valve replacement outcomes in a large multicenter cohort. Am J Cardiol 2016; 118: 1888–1896.
- 27 Alqahtani F, Aljohani S, Boobes K, Maor E, Sherieh A, Rihal CS, Holmes DR, Alkhouli M. Outcomes of transcatheter and surgical aortic valve replacement in patients on maintenance dialysis. Am J Med, 2017. https://doi.org/10.1016/j.amjmed.2017.05.031. Epub ahead of print. Accessed June 14, 2017.
- 28 Urena M, Webb JG, Tamburino C, Munoz-Garcia AJ, Cheema A, Dager AE, Serra V, Amat-Santos IJ, Barbanti M, Imme S, Briales JHA, Benitez LM, Al Lawati H, Cucalon AM, Garcia del Blanco B, Lopez J, Dumont E, DeLarochelliere R, Ribeiro HB, Nombela-Franco L, Philippon F, Rodes-Cabau J. Permanent pacemaker implantation after transcatheter aortic valve implantation: Impact on late clinical outcomes and left ventricular function. Circulation 2014; 129: 1233–1243.
- 29 Bates MG, Matthews IG, Fazal IA, Turley AJ. Postoperative permanent pacemaker implantation in patients undergoing trans-catheter aortic valve implantation: What is the incidence and are there any predicting factors? Interact Cardiovasc Thorac Surg 2011; 12: 243–253.
- 30 Dawkins S, Hobson AR, Kalra PR, Tang AT, Monro JL, Dawkins KD. Permanent pacemaker implantation after isolated aortic valve replacement: Incidence, indications, and predictors. Ann Thorac Surg 2008; 85: 108–112.
- 31 Erdogan HB, Kayalar N, Ardal H, Omeroglu SN, Kirali K, Guler M, Akinci E, Yakut C. Risk factors for requirement of permanent pacemaker implantation after aortic valve replacement. J Cardiac Surg 2006; 21: 211–215.
- 32 Bagur R, Manazzoni JM, Dumont E, Doyle D, Perron J, Dagenais F, Mathieu P, Baillot R, Charbonneau É, Metrás J, Mohammadi S, Côté M, Philippon F, Voisine P, Rodés-Cabau J. Permanent pacemaker implantation following isolated aortic valve replacement in a large cohort of elderly patients with severe aortic stenosis. Heart 2011; 97: 1687–1694.
- 33 Fadahunsi OO, Olowoyeye A, Ukaigwe A, Li Z, Vora AN, Vemulapalli S, Elgin E, Donato A. Incidence, predictors, and outcomes of permanent pacemaker implantation following transcatheter aortic valve replacement. JACC Cardiovasc Interv 2016; 9: 2189.
- 34 Incalzi RA, Gemma A, Capparella O, Muzzolon R, Antico L, Carbonin PU. Effects of hospitalization on affective status of elderly patients. Int Psychogeriatr 1991; 3: 67–74.
- 35 Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993; 118: 219–223.
- 36 FitzGerald JD, John Boscardin W, Hahn BH, Ettner SL. Impact of the medicare short stay transfer policy on patients undergoing major orthopedic surgery. Health Serv Res 2007; 42: 25–44.
- 37 Ailawadi G, LaPar DJ, Speir AM, Ghanta RK, Yarboro LT, Crosby IK, Lim DS, Quader MA, Rich JB. Contemporary costs associated with transcatheter aortic valve replacement: A propensity-matched cost analysis. Ann Thorac Surg 2016; 101: 154–161.
- 38 Attizzani GF, Alkhalil A, Padaliya B, Tam C, Lopes JP, Fares A, Bezerra HG, Medallion B, Park S, Deo S, Sareyyupoglu B, Parikh S, Zidar D, Elgudin Y, Popovich K, Davis A, Staunton E, Tomic A, Mazzurco S, Avery E, Markowitz A, Simon DI, Costa MA. Comparison of outcomes of transfemoral transcatheter aortic valve implantation using a minimally invasive versus conventional strategy. Am J Cardiol 2015; 116: 1731–1736.
- 39 Babaliaros V, Devireddy C, Lerakis S, Leonardi R, Iturra SA, Mavromatis K, Leshnower BG, Guyton RA, Kanitkar M, Keegan P, Simone A, Stewart JP, Ghasemzadeh N, Block P, Thourani VH. Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimalist approach) versus hybrid operating room (standard approach): Outcomes and cost analysis. JACC Cardiovasc Interv 2014; 7: 898–904.
- 40 Reynolds MR, Magnuson EA, Lei Y, Wang K, Vilain K, Li H, Walczak J, Pinto DS, Thourani VH, Svensson LG, Mack MJ, Miller DC, Satler LE, Bavaria J, Smith CR, Leon MB, Cohen DJ. Cost-effectiveness of transcatheter aortic valve replacement compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: Results of the PARTNER (Placement of Aortic Transcatheter Valves) Trial (Cohort A). J Am Coll Cardiol 2012; 60: 2683–2692.
- 41 Kappetein AP, Head SJ, Généreux P, Piazza N, van Mieghem NM, Blackstone EH, Brott TG, Cohen DJ, Cutlip DE, van Es GA, Hahn RT, Kirtane AJ, Krucoff MW, Kodali S, Mack MJ, Mehran R, Rodés-Cabau J, Vranckx P, Webb JG, Windecker S, Serruys PW, Leon MB. Updated standardized endpoint definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 Consensus Document. J Thorac Cardiovasc Surg 2013; 145: 6–23.
- 42 DeShazo JP, Hoffman MA. A comparison of a multistate inpatient EHR database to the HCUP Nationwide Inpatient Sample. BMC Health Serv Res 2015; 15: 384.
