Background

Therapy for symptomatic aortic stenosis in patients with concomitant moderate-to-severe chronic kidney disease may be performed using transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in a subgroup of patients according to ACC/AHA and to recent ESC/EACTS guidelines, despite slight differences in recommended age limits (65-80 years and <75 years in American and European guidelines, respectively). In such cases, based on the local heart team evaluation, a final therapeutic decision is made taking into account individual factors, after a discussion with the patient. Chronic kidney disease is a prognostic factor in aortic stenosis patients, with CKD stage ≥ 3a and ≥ 3b being a significant independent risk factor for SAVR and TAVI, respectively.

Objective and methods

We aimed at comparing TAVI vs. SAVR in patients with a moderate-to-severe chronic kidney disease (CKD stages 3a, 3b, and 4) for whom both TAVI and SAVR could possibly be considered (age ≤80 years, STS-score 4-8). Data from the large nation-wide German Aortic Valve Registry (GARY) were used. A propensity score method was used to select 706 patients undergoing TAVI and 390 undergoing SAVR. One-year survival was the primary endpoint. Secondary endpoints were clinical complications and particularly the need for postprocedural new onset dialysis.

Results

One-year survival was similar for TAVI and SAVR, with HR (95% CI) for TAVI being 1.23 (0.76, 2.02), p=0.240, and no significant divergence in Kaplan-Meier curves. In spite of post-procedural short-term survival being numerically higher for TAVI patients and 1-year survival being numerically higher for SAVR patients, such differences did not reach statistical significance (96.3% vs. 95.0%, p-value=0.538, and 81.4% vs. 85.8%, p-value=0.232, respectively). In weighted analyses, permanent pacemaker implantation, vascular complications, and more-than-mild aortic regurgitation were significantly more common in TAVI patients, whereas SAVR-treated patients had significantly higher rates of myocardial infarction, bleeding requiring transfusion, TIA and a higher length of ICU-stay and overall hospital stay. New onset temporary dialysis was required more frequently in SAVR patients (p <0.0001); however, need for chronic dialysis was very uncommon and similar in both patient groups.

Conclusion

Both TAVI and SAVR led to comparable and excellent results in patients with moderate-to-severe CKD in a matched population of patients with symptomatic severe aortic stenosis for whom both therapies could possibly be considered.