Would a patient with end-stage renal disease (ESRD) and severe aortic stenosis typically undergo Transcatheter Aortic Valve Replacement (TAVR) or Surgical Aortic Valve Replacement (SAVR)?

From the Guidelines

A patient with end-stage renal disease (ESRD) and severe aortic stenosis would typically be recommended for Transcatheter Aortic Valve Replacement (TAVR) rather than Surgical Aortic Valve Replacement (SAVR). This recommendation is based on the most recent guidelines, including the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1, which suggests that TAVR is a reasonable alternative to surgical AVR in patients with severe AS who have a high or prohibitive surgical risk. ESRD significantly increases surgical risk with traditional open-heart procedures, making TAVR a preferred option due to its minimally invasive nature, which avoids cardiopulmonary bypass and reduces the risk of perioperative complications such as bleeding, infection, and hemodynamic instability requiring dialysis adjustments.

The decision to choose TAVR over SAVR should be made by a multidisciplinary heart team that considers specific factors like the patient's age, frailty, anatomical considerations, and dialysis access locations. Careful coordination between cardiology, nephrology, and anesthesiology teams is essential, with particular attention to periprocedural management of electrolytes, volume status, and anticoagulation in relation to the patient's dialysis schedule. According to the 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1, TAVR is recommended for patients with severe symptomatic AS who are unable to undergo surgical AVR due to a prohibitive surgical risk and who have an expected survival of >1 year after intervention.

Key considerations in the decision-making process include:

• The patient's predicted risk with surgery of death or major morbidity (all causes) >50% at 30 days
• Disease affecting ≥3 major organ systems that is not likely to improve postoperatively
• Anatomic factors that preclude or increase the risk of cardiac surgery, such as a heavily calcified (eg, porcelain) aorta, prior radiation, or an arterial bypass graft adherent to the chest wall
• The expected benefits and possible complications of TAVR and surgical AVR, as discussed in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1 and the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Overall, the choice of TAVR or SAVR should be individualized based on the patient's specific clinical characteristics and preferences, with careful consideration of the potential benefits and risks of each approach.

From the Research

Patient Considerations for Aortic Valve Replacement

When considering a patient with end-stage renal disease (ESRD) and severe aortic stenosis for aortic valve replacement, several factors come into play. The decision between Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR) depends on various patient-specific and procedural factors.

Comparison of TAVR and SAVR Outcomes

• Studies have shown that TAVR can be a safer and more effective option for patients with ESRD compared to SAVR, with lower operative mortality and complication rates 2, 3.
• However, TAVR outcomes in patients with ESRD are still associated with higher mortality and complications compared to patients without renal disease 4.
• SAVR, on the other hand, has been associated with higher early and late mortality, as well as adverse outcomes in patients with ESRD 5, 4.

Procedural Considerations

• TAVR is often preferred for patients with ESRD due to its minimally invasive nature, which reduces the risk of complications and mortality 3, 4.
• SAVR, while more invasive, may be considered for patients with ESRD who are younger and have fewer comorbidities 5.
• The choice between TAVR and SAVR ultimately depends on the individual patient's risk profile, comorbidities, and overall health status 2, 6.

Conclusion is not allowed, so the response will continue without it

Additional Factors to Consider

• Patients with ESRD undergoing TAVR or SAVR should be carefully selected and evaluated to determine the best treatment option 2, 5, 3, 4.
• The decision-making process should involve a multidisciplinary team, including cardiologists, cardiothoracic surgeons, and nephrologists, to ensure that all aspects of the patient's care are considered 6.
• Further studies are needed to compare the outcomes of TAVR and SAVR in patients with ESRD and to determine the optimal treatment strategy for this high-risk population 5, 6.