August 1, 2020Circulation Cardiovascular InterventionsOpen Access

Management of Aortic Stenosis in Patients With End-Stage Renal Disease on Hemodialysis

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Why the study?

Patients with end-stage renal disease on hemodialysis and aortic stenosis face a poor prognosis, and the role of TAVR in this high-risk population is debated.

Does TAVR reduce all-cause mortality compared to SAVR or conservative management in ESRD-HD patients with aortic stenosis?

Structured PICO

Does TAVR reduce all-cause mortality compared to SAVR or conservative management in ESRD-HD patients with aortic stenosis?

Population

8107 Medicare beneficiaries with end-stage renal disease on hemodialysis (ESRD-HD) and aortic stenosis in the US between 2015 and 2017

Intervention

Transcatheter aortic valve replacement (TAVR)

Comparator

Surgical aortic valve replacement (SAVR) or conservative management

Outcome

All-cause mortality compared between treatment groups and to age-sex matched mortality for ESRD-HD in the US populationhard clinical

In ESRD-HD patients with aortic stenosis, TAVR offers comparable mid-term survival to SAVR and significantly better survival than conservative management, along with reduced heart failure hospitalizations.

Implication

Neutral mortality association warrants cautious interpretation; leaves open questions for randomized confirmation.

Abstract

Background: Patients with end-stage renal disease on hemodialysis (ESRD-HD) and aortic stenosis have poor prognosis. The role of transcatheter aortic valve replacement (TAVR) in this high-risk population is debated. Methods: We compared the outcomes among ESRD-HD Medicare beneficiaries who were managed with TAVR, surgical AVR (SAVR), or conservative management for aortic stenosis between 2015 and 2017, using overlap propensity score weighting analysis to control for differences in treatment assignment. The primary outcome was all-cause mortality and was compared between treatment groups as well as to age-sex matched mortality for ESRD-HD in the US population. Secondary outcomes included trend of heart failure hospitalizations. Results: A total of 8107 ESRD-HD patients with aortic stenosis were included, 4130 (50%) underwent TAVR, 2565 (31.6%) underwent SAVR, and 1412 (17.4%) were managed conservatively. TAVR patients had more comorbidities and higher frailty compared with the other 2 groups. Thirty-day mortality was lower with TAVR compared with SAVR (4.6% versus 12.8%, P <0.01). After a median follow-up of 465 days (interquartile range, 261–759), on overlap propensity score weighting analysis, there was no difference in mortality between TAVR and SAVR (adjusted hazard ratio, 1.02 [95% CI, 0.91–1.15], P =0.7), and mortality was lower with TAVR compared with conservative management (adjusted hazard ratio, 0.53 [95% CI, 0.47–0.60], P <0.001). Standardized mortality ratios with TAVR, SAVR, and conservative management compared with age-sex matched ESRD-HD US population were 1.24, 1.27, and 1.83, respectively. The rate of heart failure admissions declined after TAVR (incidence rate ratio, 0.55 [95% CI, 0.48–0.62], P <0.001) and SAVR (incidence rate ratio, 0.76 [95% CI, 0.65–0.88], P <0.001). Conclusions: In ESRD-HD patients with aortic stenosis, mortality was lower in the short-term with TAVR compared with SAVR but comparable in the mid-term. AVR is associated with an improvement in survival and reduction in heart failure hospitalizations compared with conservative management.