Aortic Valve Prosthesis Choice in Dialysis Patients: A Review of Medicare Data

BACKGROUND: The choice between bioprosthetic or mechanical surgical aortic valve replacement (SAVR) for dialysis patients is debated. Rapid adoption of transcatheter aortic valve replacement (TAVR) complicates decision-making further. This study compared AVR prosthesis choices among dialysis patients. METHODS: Dialysis patients who underwent bioprosthetic AVR (bAVR), mechanical AVR (mAVR), and TAVR from 2009 to 2019 were queried from Medicare Provider Analysis and Review data. Two propensity score matches were performed: bAVR vs mAVR and SAVR (bAVR + mAVR) vs TAVR. Survival at 5 years was compared using restricted mean survival time (RMST). Secondary outcomes were compared using subhazard regression with death as a competing risk. RESULTS: Among 2590 patients who underwent mAVR, 4752 underwent bAVR and 7739 underwent TAVR; mean ages were 61.5, 66.6, and 73.2 years, respectively. Matching mAVR and bAVR yielded 2460 patients each. Survival was similar, with RMST of 2.67 years for mAVR and 2.60 years for bAVR (difference = -0.07, P = .170). For mAVR, gastrointestinal bleeding readmission was higher (32.7% vs 28.6%, P = .002), whereas reoperation was lower (3.6% vs. 5.8%, P < .001). Matching SAVR and TAVR yielded 2709 patients each. SAVR had worse early but improved 5-year survival, with RMST of 2.43 vs 2.18 years (difference = -0.25, P < .001). Readmissions for gastrointestinal bleeding (∼31%) and reoperation (∼3%) were similar. CONCLUSIONS: Dialysis patients undergoing SAVR and TAVR have poor survival, high bleeding risk, and low reoperation rate regardless of prosthesis choice. Our data suggest no difference in 5-year overall survival between bAVR and mAVR, whereas SAVR was associated with worse early but improved 5-year overall survival compared with TAVR.