Is transcatheter aortic valve implantation (TAVI) appropriate for a patient with end‑stage chronic kidney disease on maintenance hemodialysis who has severe symptomatic aortic stenosis?

TAVI in End-Stage Renal Disease on Maintenance Hemodialysis

TAVI is a reasonable and safe option for patients with end-stage chronic kidney disease on maintenance hemodialysis who have severe symptomatic aortic stenosis, provided they meet standard anatomical criteria and have acceptable life expectancy beyond 12 months with potential for quality of life improvement. 1, 2

Key Evidence Supporting TAVI in Dialysis Patients

The available evidence, while limited, demonstrates that TAVI can be performed safely in hemodialysis patients:

• 30-day mortality in dialysis patients undergoing TAVI is comparable to or lower than non-dialysis CKD patients (0-3% in dialysis cohorts versus 3.17% overall in mixed CKD populations) 1, 2
• Six-month survival rates are similar between dialysis and non-dialysis CKD patients undergoing TAVI 1
• Procedural success rates exceed 97% in dialysis populations 1, 2

Critical Pre-Procedural Assessment

Before proceeding, you must verify the patient meets these criteria through multidisciplinary Heart Team evaluation 3:

Anatomical Requirements

• Aortic annulus 18-25 mm (balloon-expandable) or 20-27 mm (self-expandable devices) 3, 4
• Exclude bicuspid valve (high risk of incomplete deployment) 3, 4
• No asymmetric heavy calcification that could compress coronary arteries 3, 4
• Aortic root ≥45 mm at aorto-tubular junction for self-expandable valves 3, 4
• No LV apical thrombus 3, 4

Vascular Access Evaluation

For transfemoral approach (preferred in dialysis patients to avoid surgical stress):

• Iliac/femoral arteries ≥6-9 mm diameter (device-dependent) 3, 4
• Assess for severe calcification, tortuosity, or prior aorto-femoral bypass 3, 4
• Use CT angiography rather than contrast angiography when possible to minimize contrast load 3, 5

Life Expectancy and Quality of Life

• Expected survival >12 months post-procedure with acceptable quality of life 6, 7
• Severe symptoms definitively attributable to aortic stenosis (not uremia or other comorbidities) 3
• Exclude patients with comorbidities preventing quality of life improvement 6

Dialysis-Specific Considerations

Contrast Minimization Strategy

• Zero-contrast or ultra-low contrast TAVI protocols should be strongly considered in dialysis patients 5
• Zero-contrast TAVI shows comparable procedural success (97%) with reduced acute kidney injury risk (RR 0.47) in CKD patients 5
• Use echocardiography and fluoroscopy-guided techniques to minimize contrast exposure 5

Expected Outcomes in Dialysis Patients

Advantages:

• Lower risk of contrast-induced nephropathy (already on dialysis) 8
• Shorter hospital stays compared to surgical AVR in dialysis patients (22.5 vs 29.5 days) 1
• Lower risk of requiring new dialysis compared to surgical AVR (12.4% vs 21.2% at 2 years in advanced CKD) 9

Challenges:

• Higher permanent pacemaker requirement (4-24%, higher with self-expandable valves) 4, 5
• Longer hospital stays than non-dialysis patients (21.8 vs 12.1 days) 1
• Two-year mortality 31-53% in dialysis/transplant populations, primarily from non-cardiac causes (sepsis) 2

TAVI vs Surgical AVR in Dialysis Patients

TAVI is preferred over surgical AVR in dialysis patients when transfemoral access is feasible 1, 9:

• Lower 30-day mortality trend with TAVI (7.1% vs 2.9% for SAVR in advanced CKD, though not statistically significant) 9
• Significantly lower acute kidney injury rates with TAVI versus SAVR 9
• Lower blood transfusion requirements with TAVI 9
• Lower stroke risk with TAVI 9

However, SAVR showed somewhat better 2-year survival (23.4% vs 31.2% mortality) in CKD stages 3b-5, though this difference was not statistically significant 9

Common Pitfalls to Avoid

• Do not refuse TAVI solely based on dialysis status—the evidence shows safety and feasibility 1, 2
• Avoid excessive contrast use—implement zero-contrast protocols when possible 5
• Do not overlook infection risk—sepsis is the leading cause of mid-term mortality in this population, not cardiac causes 2
• Ensure realistic prognostic discussions—while procedural outcomes are good, 2-year mortality remains substantial due to comorbidities 2
• Screen for kidney transplant recipients separately—they may have higher mid-term mortality (53% at 2 years) and different AKI patterns 2

Procedural Approach

Transfemoral access is strongly preferred over transapical in dialysis patients to minimize surgical trauma and infection risk 1, 9. The procedure should be performed in a hybrid suite with cardiac surgery backup available 6, 4.