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Valve replacement surgery in severe chronic kidney disease
Min Ho Ju1, Sung-Ho Jung1, Suk Jung Choo1
1Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
Insights
For patients with severe chronic kidney disease (CKD) undergoing heart valve surgery, bioprosthetic replacement offers similar survival to mechanical valves but with fewer complications. This suggests bioprosthetic valves may be a safer choice for this high-risk population.
Area of Science:
- Cardiology
- Nephrology
- Surgical Innovation
Background:
- Long-term outcomes of prosthetic heart valve choices in severe chronic kidney disease (CKD) patients remain unclear.
- Severe CKD significantly impacts patient health and surgical risk.
Purpose of the Study:
- To compare the long-term outcomes of mechanical versus bioprosthetic heart valve replacement in patients with stage 4 or 5 CKD.
- To evaluate survival rates and freedom from valve-related complications.
Main Methods:
- A study of 152 adult patients with stage 4 or 5 CKD undergoing heart valve surgery.
- Propensity score analysis was used to minimize selection bias between mechanical (n=92) and bioprosthetic (n=60) groups.
- Outcomes assessed included mortality and valve-related complications over a median follow-up of 22.1 months.
Main Results:
- Bioprosthetic group patients were older with poorer left ventricular function.
- Early mortality rates were similar between groups (approx. 9.9%).
- After propensity score adjustment, survival rates were similar (HR 1.03, P=0.91), but bioprosthetic replacement showed significantly better freedom from valve-related events (HR 4.49, P=0.045).
Conclusions:
- Heart valve replacement in CKD patients carries a high mortality risk.
- Mechanical valve replacement demonstrated similar survival to bioprosthetic replacement but with a higher risk of valve-related complications.
- Bioprosthetic valve replacement appears to be a more favorable option for patients with severe CKD.
Background:
The impact of prosthetic choices in patients with severe chronic kidney disease (CKD) on long-term outcomes has not been well established.
Methods:
The study involved 152 adult patients (61.6±14.1yrs.; 64 females) undergoing heart valve surgery who had stage 4 (n=87) or 5 CKD (end-stage; n=65) based on Kidney Disease Outcomes Quality Initiative Guidelines. To reduce the impact of selection bias between mechanical (n=92) and bio-prostheses groups (n=60), propensity score analyses were conducted.
Results:
Patients undergoing bioprosthetic replacement were significantly older and had poorer left ventricular function compared with those undergoing mechanical valve replacements. Early mortality rates were 10.0% in the Bio-prostheses group and 9.8% in the Mechanical group (P>0.99). During a median duration of 22.1months (Quartile 1-3, 4.7-68.1months; 87.5% complete), 56 patients died and 12 patients experienced valve-related complications. The unadjusted outcomes showed no significant differences in survival (P=0.23) and freedom from valve-related events (P=0.17). After adjustment, there was no significant difference in survival (Hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.62-1.71; P=0.91), however the bio-prostheses group showed significant superior outcomes of freedom from valve-related event (HR, 4.49; 95% CI, 1.04-19.45; P=0.045).
Conclusions:
Valve replacement in CKD patients showed very high mortality risks and limited life expectancy even in younger individuals. When compared with bioprosthetic replacement, mechanical valve replacement showed similar survival rate but with greater risks of developing major valve-related complications in these patients. Therefore, bioprosthetic replacement may be a more reasonable option over mechanical replacement in these high-risk patients.