Increased Rate of Intermediate-Term Valve Failure After TAVR in End-Stage Renal Disease Patients Requiring Maintenance Dialysis

Abstract: Background. Transcatheter aortic valve replacement (TAVR) has been widely adopted, but outcomes in end-stage renal disease (ESRD) patients on hemodialysis (HD) have not been extensively studied. Methods. A total of 1260 TAVRs were performed at our center between December 2011 and October 2018, including 86 patients (6.82%) with ESRD on HD. Comparisons were made between baseline demographics, preoperative risk, hemodynamics, and reintervention, as well as survival at 30 days, 1 year, and 2 years. Results. Age at TAVR was 62.7 ± 12.1 years in the ESRD-HD group vs 72.3 ± 5.9 years in the non-ESRD group (P<.01). STS scores were 10.2 ± 1.3% in the ESRD-HD group vs 8.1 ± 1.1% in the non-ESRD group (P<.01). Mortality rates were different between the ESRD-HD group and the non-ESRD group (30-day mortality, 5.8% vs 3.1%, respectively [P=.05]; 1-year mortality, 25.1% vs 13.6%, respectively [P<.01]; 2-year mortality, 51.6% vs 23.0%, respectively [P<.01]). Baseline aortic valve areas (AVAs) were comparable; however, ESRD-HD patients had higher gradients than non-ESRD patients at every postprocedural interval assessed (30-day AVA, 1.47 ± 0.2 cm² vs 1.32 ± 0.1 cm², respectively [P<.001]; 1-year AVA, 1.39 ± 0.1 cm² vs 1.05 ± 0.1 cm², respectively [P<.01]; 2-year AVA, 1.28 ± 0.1 cm² vs 0.77 ± 0.05 cm² , respectively [P<.01]). Repeat TAVR was needed within 2 years in 5 ESRD-HD patients (6.8%) and 1 non-ESRD patient (0.01%). Conclusions. In our single-center cohort, the ESRD-HD TAVR group demonstrated significantly higher rates of need for valvular reintervention (6.8% vs 0.01%) at 2 years, as well as higher mortality rates at 30 days, 1 year, and 2 years.  

J INVASIVE CARDIOL 2019;31(10):307-313.

Key words: accelerated valve failure, ESRD on hemodialysis, restenosis, TAVR

Cardiovascular disease is the primary cause of mortality in patients with end-stage renal disease (ESRD) requiring hemodialysis (HD).¹ This medically  complex cohort of patients is also at increased risk for calcific valvular and perivalvular structural disease, rapidly progressive aortic stenosis (AS),^2-4 and valvular degeneration through a combination of mechanical stress and dystrophic calcification.^3,5-7 Previous studies have shown that ESRD-HD patients typically present with severe AS more than 10 years earlier than those with normal renal function,⁸ with poorer long-term outcomes after aortic valve replacement (AVR) compared with non-ESRD patients who underwent the same procedure.^8-10 

Given the elevated risk of surgical approaches for AS in ESRD-HD patients, catheter-based approaches offer potentially lower risk and better outcomes. However, use of transcatheter AVR (TAVR) in HD patients has not been extensively studied; ESRD-HD patients were excluded from randomized arms of the pivotal PARTNER and SURTAVI trials and have been enrolled only in a small registry in the CoreValve US expanded-use study. One-year outcomes after TAVR performed in ESRD-HD patients were recently published as part of a non-randomized assessment of TAVR use in extreme-risk patients (96 ESRD patients) previously excluded from clinical trials.¹¹ Early mortality rates were noted (5.3% at 30 days; 30.3% at 1 year), and were consistent with data published previously on extreme-risk patients without ESRD.¹¹ Additionally, the study authors noted infrequent vascular complications at 1 year (ie, stroke or transient ischemic attack rate, 2.1%; major vascular injury rate, 5.2%) with valve hemodynamics that remained overall improved at 1 year post TAVR. Data past 1 year were not reported. Small observational studies involving use of TAVR in dialysis patients with AS have shown additional advantages of TAVR over surgical AVR (SAVR), including reduced length of index hospital stay with lower costs of inpatient care,^12,13 and with survival rates comparable to SAVR.^12,13 

TAVR graft durability in patients requiring maintenance dialysis. ESRD requiring maintenance dialysis has been shown to promote accelerated valve degeneration through a combination of physiologic and hemodynamic stressors. Widespread calcification of the vasculature and of the valves of the heart in ESRD-HD patients reflects acquired disorders of calcium and phosphorus of renal failure.^14,15 The subsequent onset of valvular stenosis from calcification creates turbulent blood flow across the valve, and secondary elevations in pressure gradients contribute to an overall increased shear stress on the valve itself.¹⁴ Further compounding this is the frequent finding of hypertension and increased cardiac output in dialysis patients.^8,9,14 In previous years, mechanical valves were recommended for all SAVR procedures in ESRD-HD patients, given this known phenomenon of calcific degeneration and possibility of accelerated bioprosthetic valve failure; however, recent studies^9,16 have shown the overall shortened life expectancy of ESRD-HD patients is not changed significantly whether bioprosthetic or mechanical valves are used. 

Currently, the long-term durability of TAVR grafts in general is still under study, although the PARTNER 1 trial showed excellent durability at 5 years post procedure in non-dialysis patients,¹⁷ and recent studies have estimated clinically significant valve deterioration at 10 years post procedure to be approximately 7%.¹⁸ 

Longitudinal approach with 2-year outcomes after TAVR. While a consensus is emerging that TAVR is preferred over SAVR for AS in ESRD-HD patients, more data beyond the 1-year postoperative mark are needed, including more studies on valvular restenosis, thrombosis, and rates of prosthetic TAVR valve degeneration. In this study, we retrospectively analyzed a prospectively gathered clinical database and looked at outcomes at 30 days and at 1 and 2 years following index TAVR for ESRD-HD patients. We assessed changes in valvular hemodynamics over time and rate of operative reintervention post index procedure, and suggest recommendations for ongoing surveillance in this unique cohort of medically complex patients prone to calcific structural disease. 

Methods

Registry design. A secure in-house registry of 1260 patients who underwent TAVR between May 2012 and October 2018 was created as part of a retrospective quality-review study of TAVRs and subsequent patient outcomes. A total of 86 patients were identified with preoperative diagnoses of ESRD and need for maintenance dialysis, and were compared against the group of patients without dialysis requirement. All patients were evaluated preoperatively by a multidisciplinary structural heart team at our institution consisting of structural heart cardiologists, cardiothoracic surgeons, and advanced practice clinicians. As part of this evaluation, patients underwent preoperative cardiac catheterization, transthoracic echocardiogram (TTE), pulmonary function testing, dental panoramic imaging, and chest x-ray screening. All patients received preoperative cardiac computed tomography (CT) scans for the purpose of optimal preoperative characterizations of valvular anatomy and vascular access.

Retrospective quality review. Patient charts were reviewed with attention to the following: (1) demographics, including age and gender; and (2) past medical history, including ESRD with chronic HD maintenance requirement, type II diabetes, chronic obstructive pulmonary disease (COPD), need for home oxygen, and previous coronary artery bypass graft (CABG) surgery. Additional preoperative factors included New York Heart Association (NYHA) failure classification, preoperative left ventricular ejection fraction (LVEF), and pulmonary artery pressure (PAP). Assessments of preoperative risk for each patient were made using the online Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Risk Calculator (https://riskcalc.sts.org/stswebriskcalc/#/calculate). Standard frailty assessment was used to predict risk of mortality in TAVR procedures.¹⁹ Lastly, the number of admissions for heart-failure related reasons was quantified by chart review for 1 year and 2 years prior to the index procedure. Post-TAVR data were prospectively collected and retrospectively analyzed; this included valve function at baseline and at 30 days, 1 year, and 2 years, as assessed by TTE. Mortality rates were also assessed at 30 days, 1 year, and 2 years. Need for valvular reintervention for restenosis and infective endocarditis was also measured.

Echocardiography core lab analyses. All measurements and analyses were performed by the echocardiography core lab of a single tertiary referral center, without knowledge of clinical data, laboratory data, and study inclusion criteria. An average of 3 cardiac cycles was used for sinus rhythm, and an average of 3 to 5 cardiac cycles was used for atrial fibrillation. If arrhythmia or poor image quality prevented quantitative measurements, LVEF was estimated visually. Interobserver variability in measuring LV volumes was determined in a subset of patients. LVEF was measured primarily by the Simpson’s volumetric method whenever possible. Either a combination of apical 4-chamber and 2-chamber views (preferentially) or a combination of apical 4-chamber and long-axis views was used. The severity of mitral regurgitation (MR) was primarily determined by the physician’s visual assessment of width, depth, and area of the MR jet. In addition, effective regurgitant orifice was determined using the proximal isovelocity surface area method, as previously described,²⁰ whenever possible. Pulmonary artery systolic pressure was estimated from the peak tricuspid regurgitation (TR) velocity, obtained by continuous-wave Doppler echocardiography, and estimated right atrial pressure, as previously described.²⁰

Procedural descriptions. All TAVRs were performed at a single large institution by a single team in a specially equipped hybrid suite with a heart-lung machine available in the room in case of hemodynamic compromise. Valve sizing was done in accordance with published recommendations.²¹ Edwards Lifesciences valves (original Sapien, Sapien XT, Sapien 3) or Medtronic valves (CoreValve, Evolut R, and Evolut Pro) were used in all cases. The valve was introduced through a femoral, subclavian, transapical, direct aortic, or transcaval approach based on patient anatomy, positioned, and then deployed into the aortic valve (AV) under fluoroscopic guidance. Final TTE or transesophageal echocardiogram (TEE) was then performed to assess final position, presence of central or paravalvular leaks, transvalvular gradients, and motion of valvular leaflets after valve placement. Follow-up TTEs were employed prior to discharge and at each outpatient exam. Presence or absence of ESRD was not an intentional independent factor in method of sedation, access route, or valve selection, with the same selection criteria and preoperative assessment applied across the entire population by the structural heart team.

Assessment of postoperative outcomes with longitudinal follow-up. Included within a secure, HIPAA-compliant database were procedural details specific to the TAVR procedure, including type of valve used, approach employed, and whether acute procedural success was achieved. Additional postoperative complications were assessed during the hospital stay, and included need for operative valvular reintervention at any time and pacemaker placement at any time during the first 2 years post operatively for this study. Postoperative TTEs were performed at outpatient follow-up exams at 1-month and 12-month intervals initially, and at annual office visits thereafter. Performance measures, both short and long term, were documented at each visit, and included hospital readmissions, freedom from reoperative intervention, valve embolization or thrombosis by TTE, myocardial or cerebrovascular insults, new pacemaker requirement for arrhythmia, and gastrointestinal bleeding. All causes of mortality were also noted. Throughout the study period, the institution employed the same electronic medical record system (EPIC Systems), which facilitated data collection.

TAVR valve-in-valve (ViV) procedures. Five ESRD patients and 1 non-ESRD patient from the original cohort of 1260 patients underwent redo TAVRs; outcomes are reported as part of this study. Unless indicated, identical replacement valve type and size were used, or as close as possible with the latest-generation valve analogous to the original implant. 

Study design and statistical analysis. Categorical data presented herein were tabulated and are presented as percentages or frequencies; continuous variables are expressed as mean ± standard deviation or median (range), where appropriate. Estimates of overall survival were determined using Kaplan-Meier non-parametrics. P-values ≤.05 were considered statistically significant. 

Results

Demographics and preoperative clinical assessments. Between December 2011 and October 2018, a total of 1260 patients underwent TAVR at our institution; of these, 86 patients (6.82%) had a previous diagnosis of ESRD requiring maintenance dialysis for an average of 3.1 ± 1.2 years prior to index TAVR (Table 1), with the remaining 1159 patients comprising the non-ESRD group. Average age at time of TAVR procedure was 62.7± 12.1 years in the ESRD-HD group vs 72.3 ± 5.9 years in the non-ESRD group (P<.01)(Table 1). There were no statistical differences in incidences of concurrent diabetes, COPD, or requirement of home oxygen between the two groups (Table 1); however, there was an increased incidence of prior CABG in the ESRD-HD group (P<.01). The ESRD-HD group also had higher preoperative risk of mortality as assessed by the STS risk score (P<.01), with corresponding higher frailty indices (P<.01) and higher NYHA classification of symptoms compared with the non-ESRD group (P=.01) (Table 1). 

Admissions for congestive hart failure prior to TAVR. ESRD-HD patients were shown to be admitted more frequently for symptoms of congestive heart failure prior to index TAVR at 1 year prior to TAVR (6.8 ± 0.5 admissions in the ESRD-HD group vs 4.3 ± 0.3 admissions in the non-ESRD group; P<.01) and at 2 years prior to TAVR (3.9 ± 0.4 admissions in the ESRD-HD group vs  2.0 ± 0.5 admissions in the non-ESRD group; P<.01) (Table 1). 

Preoperative assessments with echocardiogram. There was no statistical difference in EF (P=.20) (Table 2), although PAP was significantly higher in the ESRD on HD cohort (67.3 ± 8.1 mm Hg vs 54.2 ± 7.2 mm Hg in the non-ESRD group; P<.01) (Table 2). Aortic valve area (AVA) was calculated as 0.55 ± 0.2 cm² in the ESRD-HD group vs 0.78 ± 0.1 cm² in the non-ESRD group (P<.01) (Table 2). Mean AV gradients were higher in the ESRD-HD group (46.1 ± 8.4 mm Hg vs 37.8 ± 9.5 mm Hg in the non-ESRD group; P<.001) (Table 2), as were AV peak gradients (84.6 ± 14.4 mm Hg vs 68.3 ± 18.7 mm Hg in the non-ESRD group; P<.01) and AV peak velocities (423.1 ± 21.1 cm/s vs 383.4 ± 27.3 cm/s in the non-ESRD group; P=.04) (Table 2). 

Mitral and tricuspid valves. Compared with the non-ESRD group, the ESRD-HD group had statistically higher rates of ≥ grade 2 mitral annular calcification (MAC) (P<.001), ≥ grade 2 mitral stenosis (P<.01), and ≥ grade 2 tricuspid regurgitation (P<.001) (Table 2).

Postoperative outcomes following TAVR. Operative approach differed between the two groups (Figure 1); fewer ESRD-HD patients had a transfemoral approach employed (P=.05). While not a deliberate selection factor, ESRD-HD patients in general had higher rates of peripheral vascular disease. Additionally, while TAVR is currently done via TF approach >90% of the time with smaller-profile current-generation devices, these data cover the early years of TAVR, when alternative access sites were more prevalent. Acute procedural success was achieved in 85 ESRD-HD patients (98.8%), with 1 case converted to SAVR following annulus rupture, and in 1153 non-ESRD patients (99.1%), with 6 cases converted to SAVR during the planned TAVR procedure (Table 3). 

On average, the non-ESRD group required shorter postoperative intensive care unit stays (1.7 ± 0.8 days vs 2.1 ± 1.1 days in the ESRD-HD group; P=.01) and shorter overall length of hospital stays (3.9 ± 0.7 days vs 4.2 ± 1.6 days in the ESRD-HD group; P=.09) after undergoing TAVR (Table 3). 

Postoperative complications, including new pacemaker requirement and postoperative cerebrovascular attack (CVA), myocardial infarction (MI), or major gastrointestinal bleed, are shown in Table 4.There were no statistical differences in patients requiring pacemaker for postoperative arrhythmias or in postprocedural CVAs at any of the time points studied (Table 4). Postprocedural MIs following TAVR were assessed in both groups (Table 4). At 1 year, there was no significant difference between the two groups (P=.40); however, a significant difference was noted at 2 years post TAVR, where 7 of 60 ESRD-HD patients (11.7%) and 175 of 960 non-ESRD patients (18.2%) had MI (P=.05). Assessment of incidence of gastrointestinal bleeding after TAVR demonstrated no significant differences between the two groups at 30 days or 1 year post procedure (Table 4); however, a significant difference was evident at 2 years post procedure, with GI bleeds in 13.3% of ESRD-HD patients vs 9.8% of non-ESRD patients (P<.01) (Table 4). 

Mortality rates. There were no intraoperative deaths in the ESRD-HD group vs 6 intraoperative deaths in the non-ESRD cohort. Difference in total mortality rate for the first 30 days post TAVR was significant, with a higher number of deaths in the ESRD-HD group (P=.05) (Table 5). Mortality rates at 1 year and 2 years were also significantly different between groups, with more ESRD-HD patients affected (P<.01 for both time points) (Table 5).

Freedom from operative reintervention. For the first 30 days after index TAVR, there was no significant difference between the two groups regarding need for operative reintervention for any reason (100% freedom from reintervention in both cohorts) (Table 6). In the first year post TAVR, 1 patient from the ESRD-HD group underwent redo ViV-TAVR at 11.5 months, secondary to severe and progressive symptoms of AS and high surgical risk. In this patient, preoperative TEE revealed extensive calcification of the valve leaflets that had accumulated in the 10 months after her 30-day postoperative echocardiogram. A total of 1106 of 1111 patients (99.5%) in the non-ESRD group remained free of operative reintervention vs 79 of 80 patients (98.4%) in the ESRD-HD group (P=.07) (Table 6). In the non-ESRD cohort, a total of 4 patients underwent SAVR procedures necessitated by infective endocarditis involving the TAVR valve (Table 6) and 1 patient underwent ViV-TAVR redo procedure for worsening paravalvular regurgitation. Patients with endocarditis were excluded from the analysis of need for reintervention after restenosis.

During postoperative year 2, a total of 4 additional ViV-TAVRs were performed in the ESRD-HD group (at 14, 16, 16.5, and 18 months) for valve restenosis from heavy calcifications of the TAVR valve (cumulative freedom from reintervention for ESRD group = 55 of 60 patients, or 91.2%). In the non-ESRD group, there was 1 additional case requiring operative reintervention (1 SAVR procedure was performed secondary to infective endocarditis with TAVR valve involvement). Cumulative freedom from reintervention for the non-ESRD group at this time was noted to be 954 of 960 patients, or 99.3% (P=.04 vs the non-ESRD group) (Table 6). 

Hospital readmissions following index TAVR for congestive heart failure exacerbations. There were significant differences in the number of inpatient admissions for congestive heart failure in the first 30 days post TAVR, with 17 of 83 patients (20.5%) readmitted from the ESRD-HD group vs 73 of 1135 patients (6.4%) readmitted from the non-ESRD group (P<.01) (Table 6). Statistical differences between ESRD and non-ESRD groups were also evident at 1 year post TAVR, with 9 additional patient admissions in the ESRD-HD group (28 cumulative admissions at 1 year [35.2%]) and 46 additional patient admissions in the non-ESRD (119 cumulative admissions at 1 year [10.7%]) (P<.001) (Table 6). Similarly, striking differences were noted at 2 years, with 7 more admissions in the ESRD-HD group (35 cumulative admissions at 2 years [58.3%]) and 31 more admissions in the non-ESRD group (150 cumulative admissions at 2 years [14.8%]) (P<.001) (Table 6).

Longitudinal assessments of valve function after TAVR. Significant differences in EF, PAP, and mean gradient were evident at every time point surveyed between the two groups (Supplemental Table S1; supplemental materials available at www.invasivecardiology.com) (P≤.05). When assessed prior to hospital discharge after index TAVR, both peak gradient and peak velocity were not significantly different between ESRD and non-ESRD groups. However significant differences in these parameters were seen at 30 days, 1 year, and 2 years post procedure (P≤.05) (Supplemental Table S1). The ESRD-HD group had significantly smaller AVAs at every time point assessed after discharge, with the ESRD-HD group reaching severe valve stenosis levels (<1 cm²) at some time between years 1 and 2 after index TAVR (Supplemental Table S1).

ViV-TAVR for restenosis following index TAVR. Six patients of the total group of 1260 TAVR patients underwent redo TAVR (ie, ViV-TAVR) during the time period under investigation, with 5 of 6 in the ESRD-HD group (Supplemental Figure S1). The single ViV-TAVR in the non-ESRD group occurred at 11.5 months post index TAVR in a 66-year-old woman with a history of discoid lupus erythematosus who had been on chronic immunosuppressive therapy for several decades. She presented with signs of acute decompensation and severely elevated gradients in the TAVR prosthesis (mean gradient, 80 mm Hg). Given hemodynamic compromise and calcific valve appearance, a trial of anticoagulation was not felt appropriate and urgent repeat TAVR was performed successfully. Data from postoperative echocardiograms and from those taken on follow-up immediately post procedure (n = 5), as well as at 30 days (n = 5), 1 year (n = 4), and 2 years (n = 4) post TAVR are shown in Supplemental Figure S2. When compared with measurements taken immediately post TAVR, significant differences were evident in every parameter assessed. AVA measured 1.28 ± 0.1 cm² post TAVR vs 1.06 ± 0.05 cm² at 30 days (P<.05) vs 0.86 ± 0.06 cm² at 1 year (P<.01) vs 0.77 ± 0.10 cm² at 2 years (P<.001), while mean gradient measured 8.8 ± 5.1 mm Hg post TAVR vs 15.1 ± 7.2 mm Hg at 30 days (P<.05) vs 25.7 ± 6.4 mm Hg at 1 year (P<.01) vs 34.2 ± 6.9 mm Hg at 2 years (P<.001). There were no significant differences noted in peak velocity when postoperative values were compared against those noted at 30 days post TAVR (P>.05); however, these values were statistically different (P<.001) at 1 year and 2 years.

Predictors of accelerated valve failure after TAVR. Differences between the 5 ESRD-HD patients who underwent ViV-TAVR during the time period of this study and the ESRD-HD group who did not require redo were reviewed. Four of the 5 ViV-TAVR patients (80.0%) in the ESRD-HD group had required permanent pacemaker placement after the index procedure. It was also noted that average cumulative dialysis requirement was significantly longer in the 5 patients in the redo TAVR group (9.2 ± 1.8 years vs 2.8 ± 0.9 years in the 78 patients in the ESRD-HD group who did not require redo TAVR; (P<.01). All 5 ESRD-HD patients (100%) who underwent ViV-TAVR had previous diagnoses of secondary hyperparathyroidism associated with ESRD, as well as history of chronic serum elevations in calcium, phosphate, and parathyroid hormone levels. In contrast, only 30 of 78 patients (38.0%) in the overall ESRD-HD group were diagnosed with secondary hyperparathyroidism. 

Discussion

In this study, we present a single-center retrospective analysis of prospectively collected data on longitudinal outcomes of a large cohort of patients undergoing TAVR, and compare the outcomes in ESRD-HD patients with non-ESRD patients. The ESRD-HD group was younger, but had more extensive comorbidities, higher baseline gradients, and higher preoperative surgical risks when compared with the non-ESRD group. We report similar acute procedural success rates, but higher gradients at 30 days, 1 year, and 2 years. While registry reports from SURTAVI showed no need for reintervention in a similarly sized ESRD cohort at 1 year, we noted significant need for repeat intervention in the ESRD-HD group for valvular degeneration in the 1-2 year period. 

Our data strongly suggest that while outcomes for TAVR in the ESRD-HD group may be superior to historical SAVR results, they are not as durable as TAVR in the general non-ESRD population; thus, different approaches might be needed for counseling preoperative and post-TAVR management. Reintervention rates in the intermediate term are sharply elevated and should prompt careful consideration of closer surveillance. Additionally, these data raise interesting questions regarding valve selection at the index procedure as part of a possible multivalve strategy over the course of the ESRD-HD patient’s treatment. The association of duration of maintenance dialysis requirement with concurrent diagnosis of secondary hyperparathyroidism of renal origin also correlated with accelerated valvular calcification and need for reintervention in this study — a phenomenon that has been previously documented.^21-27 As renal function declines, homeostatic mechanisms of regulating serum calcium and phosphorus are disrupted, ^23,24,27 leading to pathologic bone remodeling, inflammation, and decreased levels of systemic calcification inhibition.^23,24,27 As the parathyroid glands hypertrophy under these conditions, this in turn creates what has been previously described as a “perfect storm” for accelerated deposition of calcifications within the vasculature and within the valvular apparatus of the heart.²⁴ Furthermore, this phenomenon appears to worsen with duration of dialysis requirement.^24-27 In the present study, the group of ESRD-HD patients who required ViV-TAVR had required maintenance dialysis >3 times longer than the ESRD-HD patients who did not require ViV-TAVR reintervention. 

Study limitations. This study has a number of limitations. It is a single-center experience, and results at other sites might vary. These data are observational. The overall number of ESRD-HD patients included in the study was relatively small compared with the overall cohort, although it was comparable to other published data. In addition, this analysis only included patients from the study cohorts with 2 full years of data available between the years of 2012-2018, and it reflects the changing trends of procedural approach and technique as the TAVR field evolved and developed. Furthermore, the study does not specifically address patients who underwent TAVR, subsequently developed ESRD following the index procedure, and later required maintenance dialysis.

As the number of patients requiring long-term dialysis increases yearly, and the use of TAVR for the treatment of AS is expected to expand to patients of all degrees of surgical risk, more studies are needed regarding the management of AS in patients on chronic dialysis. 

Conclusion

Patients with end-stage renal failure requiring long-term dialysis present at younger ages, with AS that is more severe than patients without renal impairment. We show here that TAVR is a feasible and safe procedure for ESRD-HD patients, but that this group of medically complex patients is at increased risk of restenosis of the TAVR valve from calcific structural degeneration, and increased risk for operative reintervention after the first postoperative year following the index TAVR. 

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From the Sentara Heart Hospital, Heart Valve and Structural Disease Center, Norfolk, Virginia.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Mahoney is a consultant and proctor for Edwards Lifesciences and Medtronic. Dr Long reports no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript submitted May 1, 2019 and accepted May 14, 2019.

Address for correspondence: Paul Mahoney, MD, Sentara Heart Hospital, Heart Valve and Structural Disease Center, 600 Gresham Drive, Norfolk, VA 23507. Email: paul.mahoney.md@gmail.com