Corresponding Author
Key words: aortic valve stenosis, balloon-expandable valves, hemodialysis, self-expandable valves, transcatheter aortic valve replacement
Transcatheter aortic valve implantation (TAVI) has become the default treatment option for aortic stenosis (AS) in many international guidelines.1,2 It has evolved from treating only high-risk patients to the standard of care, based on many randomized trials and large registries. Despite all these data, a few aspects remain unanswered, such as performing TAVIs in certain high-risk populations that are known to have poor prognosis. Particularly hemodialysis patients and their treatment are challenged by earlier onset of AS, higher prevalence of atherosclerosis, higher calcification of the aortic valve, and multimorbidity leading to shorter live expectancy. In addition, quality of life is already reduced because of hemodialysis and multimorbidity, resulting in even more pronounced reduction with the onset of severe AS. In the early years of TAVI, hemodialysis patients were among those, who fulfilled the criteria of being inoperable or high risk for surgery, thus being eligible for TAVI. At the same time, they were often considered too sick even for TAVI, with more expected procedural complications and lower life expectancy. Therefore, understanding the risk-benefit distribution in hemodialysis patients was always clinically very relevant.
In this issue of JACC: Asia, Iwata et al3 analyzed data of the large multicenter OCEAN-TAVI registry comparing hemodialysis patients with non-hemodialysis patients who underwent TAVI, both without matching and with propensity score matching. As expected, the unmatched comparison showed a significantly higher mortality in the hemodialysis group. Interestingly, propensity matching attenuated this difference, showing similar mortality. The most important conclusion of this paper is that hemodialysis is an independent prognostic risk factor, but the poor prognosis of these patients is mainly related to the overall multimorbidity that is prevalent in this patient group.
How do these results correspond to the literature? A comparable concept was used in a publication by Higuchi et al.4 This paper used the LAPLACE-TAVI registry to compare hemodialysis patients with non-hemodialysis patients undergoing TAVI, both in an unmatched and matched comparison. The results were quite similar to the Iwata et al3 paper, showing a higher mortality in the hemodialysis group without matching, but no significant difference after adjusting for confounders. They also concluded that comorbidities have the major influence on prognosis. This further confirms the findings of the paper by Iwata et al.3
One of the major limitations in this study is the rather short follow-up time. It is very likely that with longer follow-up, hemodialysis will get a stronger influence on prognostic aspects and morbidity. A paper by Mizote et al5 analyzed 5-year follow-up of hemodialysis patients after TAVI. While periprocedural mortality was comparable with that among nonhemodialysis patients, 5-year mortality was expectedly higher in hemodialysis patients (however, without propensity score matching), and more importantly, prosthesis failure was significantly higher. A lower durability of bioprostheses in hemodialysis patients is a known problem and most likely directly related to hemodialysis and not necessarily multimorbidity.
In summary, the results of the Iwata et al3 paper are very important for our daily decision-making in patients with AS. Hemodialysis per se should not be a reason to advise against TAVI. However, the overall multimorbidity of these patients may play a role in the decision to perform or avoid TAVI. A sufficient overall prognosis and realistic improvement of life expectancy and quality of life is an important requirement for treating hemodialysis patients with TAVI. We should also keep in mind that hemodialysis patients with AS not only suffer from reduced quality of life, but severe AS impairs the ability to perform hemodialysis, due to hypotension during the volume loss. Very often, this is the main symptom of hemodialysis patients with severe AS, since many of these patients are not very active and do not necessarily experience shortness of breath. Impairing dialysis puts them at risk and significantly reduces quality of life.
In conclusion, TAVI should be offered to hemodialysis patients with severe symptomatic AS, as done with nonhemodialysis patients, but prognostically relevant comorbidities have to be taken into account in the decision process.
Funding Support and Author Disclosures
The author has reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
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References
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