Valve Selection for the Aortic Position in Dialysis Patients

Five-Year Transcatheter Aortic Valve Replacement Outcomes in Chronic Hemodialysis vs. Non-Hemodialysis Patients Using Balloon-Expandable Devices

BACKGROUND

Based on the results of a clinical trial in Japan, transcatheter aortic valve replacement (TAVR) for hemodialysis (HD) patients gained approval; however, mid-term TAVR outcomes and transcatheter aortic valve (TAV) durability in HD patients remain unexplored.Methods and Results: We analyzed background, procedural, in-hospital outcome, and follow-up data for 101 HD patients and 494 non-HD patients who underwent TAVR using balloon-expandable valves (SAPIEN XT or SAPIEN 3) retrieved from Osaka University Hospital TAVR database. Periprocedural mortality and TAVR-related complications were comparable between HD and non-HD patients. However, Kaplan-Meier analysis revealed that HD patients had significantly lower survival rates (log-rank test, P<0.001). In addition, HD patients had significantly higher rates of severe structural valve deterioration (SVD) than non-HD patients (Gray test, P=0.038).

CONCLUSIONS

TAVR in HD patients had comparable periprocedural mortality but inferior mid-term survival and TAV durability than in non-HD patients. Indications for TAVR in younger HD patients should be carefully determined, considering the possibility of a TAV-in-TAV procedure when early SVD occurs.

Prosthesis Choice in Dialysis Patients Undergoing Mitral Valve Replacement

BACKGROUND

Patients with renal disease on dialysis have significant comorbidity limiting life expectancy; however, these patients may experience accelerated prosthetic valve degeneration. The purpose of this study was to examine the impact of prosthesis choice on outcomes in dialysis patients undergoing mitral valve replacement (MVR) at our high-volume academic center.

METHODS

Adults undergoing MVR were retrospectively reviewed between January 2002 and November 2019. Patients were included if they had documented renal failure and dialysis requirements before presentation. Patients were stratified by mechanical vs bioprosthetic prosthesis. Death and recurrent severe valve failure (3+ or greater) or redo mitral operation were used as primary outcomes.

RESULTS

There were 177 dialysis patients identified who underwent MVR. Of these, 118 (66.7%) received bioprosthetic valves, whereas 59 (33.3%) received mechanical valves. Those who received mechanical valves were younger (48 vs 61 years; P < .001) and had less diabetes (32% vs 51%; P = .019). Prevalence of endocarditis and atrial fibrillation was similar. Postoperative length of stay was not different between groups. Risk-adjusted hazard for 5-year mortality was similar between groups (P = .668). Early mortality was high, with both groups having <50% actuarial survival at 2 years. No differences were noted in rates of structural valve deterioration or reintervention. More stroke events were noted on follow-up in patients receiving mechanical valves (15% vs 6%; P = .041). Endocarditis was the leading reason for reintervention; 4 patients received repeated surgery for bioprosthetic valve failure.

CONCLUSIONS

MVR in dialysis patients carries significant morbidity and increased midterm mortality. Decreased life expectancy should be considered in the tailoring of prosthesis choice to dialysis-dependent patients.

Mechanical vs Bioprosthetic Aortic Valve Replacement in Patients on Dialysis: Long-term Outcomes

BACKGROUND

Using the Japan National Clinical Database and additional data, this study is an analysis of long-term survival of dialysis-dependent patients who underwent aortic valve replacement (AVR).

METHODS

Dialysis-dependent patients who underwent de novo AVR between 2010 and 2012 and who were registered in the database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. Additional data on the underlying kidney disease, the duration of dialysis, and clinical outcomes were registered between October 29, 2019, and August 30, 2020. The primary outcome was all-cause mortality. The secondary outcomes were cerebral infarction, cerebral bleeding, gastrointestinal bleeding, and prosthetic valve failure.

RESULTS

After propensity score matching, 1016 cases (508 each in the bioprosthetic and mechanical valve groups) were matched. The median follow-up period was 3.29 years (interquartile range [IQR], 0.59 years, 6.25 years). The median survival time was 5.38 years (IQR, 1.20 and 9.26 years) in the mechanical valve group and 4.98 years (IQR, 1.69 and 9.62 years) in the bioprosthetic valve group. The Cox regression model showed no significant difference in long-term survival between the groups (mechanical valve: hazard ratio [HR], 0.895; 95% CI, 0.719-1.113; P = .318). The incidences of cerebral infarction and prosthetic valve failure requiring admission were similar between the groups. Cerebral bleeding (HR, 2.143; 95% CI, 1.125-4.080; P = .002) and gastrointestinal bleeding (HR, 2.071; 95% CI, 1.243-3.451; P = .0005) were more frequent in the mechanical valve group.

CONCLUSIONS

Long-term survival of dialysis-dependent patients was similar regardless of whether mechanical valves or bioprosthetic valves were implanted. The incidences of cerebral and gastrointestinal bleeding were 2-fold higher in the mechanical valve group.

Durability of Bioprosthetic Valves in Patients on Dialysis

Purpose: This study focused on clarifying the durability of bioprosthetic valves in current practice.

Methods: A total of 238 consecutive patients who underwent aortic valve replacement at a single institution from 2011 to 2020 were reviewed. We evaluated valve-related outcomes such as structural valve deterioration (SVD), especially in dialysis patients who received bioprosthetic valve.

Results: Among the tissue valves implanted in 212 patients, 5 SVDs were recorded and 3 valves were replaced. All early valve failures occurred in relatively young dialysis patients and were recorded 3 to 5 years after the initial operation. Freedom from SVD at 6 years was 49.9% in patients on dialysis, compared with 100% in non-dialysis patients. Predictors of better survival in dialysis patients were better preoperative functional class and larger prosthetic valve size.

Conclusions: The durability of bioprosthetic valves in the aortic position was suboptimal in dialysis patients. Mechanical valves can be an option for young, healthy dialysis patients with a large aortic valve annulus.

Aortic stenosis in chronic kidney disease: challenges in diagnosis and treatment

Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.

Long-Term Outcomes of Bioprosthetic or Mechanical Valve Replacement in End-Stage Renal Disease: A Nationwide Population-Based Retrospective Study

Background: Valve replacement is associated with worse outcomes in individuals who have end-stage renal disease (ESRD) and require a long-term renal replacement therapy. Prosthetic valve selection in patients with ESRD has remained controversial.

Objective: We aimed to investigate long-term outcomes of mechanical and bioprosthetic valve replacement in individuals with ESRD.

Methods: We conducted a population-based retrospective cohort study using data obtained from the Taiwan National Health Insurance Research Database. In total, 10,202 patients, including 912 ESRD and 9,290 non-ESRD patients, were selected after a 1:1 propensity-score matching based on the type of prosthetic valve used. The long-term mortality outcomes were then analyzed.

Results: During a median follow-up period of 59.6 months, the Kaplan–Meier survival analysis revealed that ESRD patients who underwent mechanical valve replacement had higher rates of all-cause mortality and CV deaths than those who underwent bioprosthetic valve replacement (Log-rank test, p = 0.03 and 0.02, respectively). Multivariable regression analyses demonstrated that ESRD patients who underwent bioprosthetic valve replacement had lower rates of all-cause mortality (p &lt; 0.001, hazard ratio: 0.88, 95% confidence interval: 0.82–0.93) and cardiovascular (CV) death (p &lt; 0.001, hazard ratio: 0.83, 95% confidence interval: 0.76–0.90) than those who had mechanical valve replacement.

Conclusion: Bioprosthetic valve replacement is significantly associated with lower rates of all-cause mortality and CV death in the ESRD population.

Strict control of phosphorus concentration of hemodialysis patients may decrease structural valve deterioration after aortic valve replacement

OBJECTIVES

The number of hemodialysis patients requiring aortic valve replacement (AVR) is increasing. Although bioprosthetic valves are increasingly popular, they are associated with a risk of structural valve deterioration (SVD). The aim of this study is to examine the outcomes of bioprosthetic valves in hemodialysis patients undergoing AVR and to identify treatment strategies that can decrease the risk of SVD.

METHODS

Between February 2010 and November 2019, 61 patients on hemodialysis underwent AVR using bioprosthetic valves at our hospital. Five patients died while still in the hospital. Kaplan-Meier estimates of overall survival and univariate Cox proportional hazards regression analyses were performed for the remaining 56 patients.

RESULTS

During follow-up, there were six SVD events (10.7%) related to the bioprosthetic valves. The survival rate was 67.9% at 3 years and 39.5% at 5 years. In all SVD cases, SVD was caused by aortic stenosis. The mean interval between AVR and the discovery of SVD was 41.5 months. The SVD-free rate was 88.6% at 3 years and 65.3% at 5 years. Preoperative phosphorus levels are associated with SVD risk. High preoperative phosphorus concentration is associated with elevated SVD risk.

CONCLUSIONS

In this study, we determined that the risk of SVD can be influenced by preoperative phosphorus level. Strict control of the phosphorus concentration of hemodialysis patients may decrease structural valve deterioration after aortic valve replacement.

Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association

Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.

Impact of dialysis in patients undergoing bioprosthetic aortic valve replacement

OBJECTIVES

To determine the incidence of bioprosthetic structural valve deterioration in dialysis patients undergoing aortic valve replacement compared to that in patients without dialysis.

METHODS

This single-centre retrospective observational study included 1159 patients who underwent aortic valve replacement using bioprosthetic valves for aortic stenosis and/or regurgitation at our institution between 2007 and 2017 [patients with dialysis (group D, n = 134, 12%) or without dialysis (group N, n = 1025, 88%)]. To adjust for potential differences between groups in terms of initial preoperative characteristics or selection bias, a propensity score analysis was conducted. The final sample that was used in the comparison included 258 patients, as follows: 129 patients with dialysis (group D) and 129 patients without dialysis (group N). The cumulative incidences of all-cause death, cardiac death and moderate or severe structural valve deterioration were estimated using the Kaplan-Meier method.

RESULTS

Operative mortality was significantly higher in group D than group N (9% vs 0%, P = 0.001). Kaplan-Meier analysis revealed that in group D, the incidence was significantly higher for all-cause death (P < 0.001, 50% vs 18% at 5 years), cardiac death (P = 0.001, 18% vs 5% at 5 years) and moderate or severe structural valve deterioration (P < 0.001, 29% vs 5% at 5 years) compared with group N.

CONCLUSIONS

The incidence of structural valve deterioration in dialysis patients undergoing aortic valve replacement was higher than that in patients without dialysis. Bioprosthetic valves should be carefully selected in dialysis patients undergoing aortic valve replacement.

Mechanical or biological heart valve for dialysis-dependent patients? A meta-analysis

OBJECTIVE

The optimal selection of prosthetic heart valve for dialysis-dependent patients remains controversial. We investigated the comparative effectiveness and safety of mechanical prosthesis (MP) and bioprosthesis (BP) for these patients.

METHODS

After the systematic review, we included studies that involved patients on dialysis undergoing aortic valve replacement or mitral valve replacement (MVR) and reported comparative outcomes of MP and BP. Meta-analysis was performed using random-effects model. We conducted a subgroup analysis based on the valve position and postoperative international normalized ratio (INR), which was extracted from either tables or methods of each study. A meta-regression was used to examine the effects of study-level covariates.

RESULTS

We included 24 retrospective studies without randomized-controlled trials, involving 10,164 participants (MP = 6934, BP = 3230). Patients undergoing aortic valve replacement with MP exhibited a better long-term survival effectiveness (hazard ratio, 0.64; 95% confidence interval [CI], 0.47-0.86). Conversely, studies including MVR demonstrated little difference in survival (hazard ratio, 0.90; 95% CI, 0.73-1.12). A meta-regression revealed that age had little effect on long-term survival difference between MP and BP (β = -0.0135, P = .433). MP had a significantly greater bleeding risk than did BP when INR was above 2.5 (incidence rate ratio, 10.58; 95% CI, 2.02-55.41). However, when INR was below 2.5, bleeding events were comparable (incidence rate ratio, 1.73; 95% CI, 0.78-3.82). The structural valve deterioration rate was significantly lower in MP (risk ratio, 0.24; 95% CI, 0.14-0.44).

CONCLUSIONS

MP is a reasonable choice for dialysis-dependent patients without additional thromboembolic risk requiring aortic valve replacement, for its better long-term survival, durability, and noninferior bleeding risk compared with BP. Conversely, BP might be an appropriate selection for patients with MVR, given its similar survival rate and lower bleeding risk. Although our meta-regression demonstrates little influence of age on long-term survival difference between MP and BP, further studies stratifying patients based on age cut-off are mandatory.

Surgical Therapy for Patients with Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement

Aortic stenosis (AS) is the most common valvular heart disease and is most frequently recognized among elderly people. Surgical aortic valve replacement (SAVR) is the most effective therapy, but its indication is sometimes difficult, and is impossible for high operative risk patients. Transcatheter aortic valve replacement (TAVR) was recently approved in Japan for high risk and inoperable patients with severe AS. TAVR is a less invasive method because it does not require a cardiopulmonary bypass and is associated with excellent surgical outcomes. In Western countries, the indication of TAVR has already been extended to moderate operative risk patients with severe AS, and is going to be further extended to low risk patients. The number of patients undergoing TAVR is increasing progressively, and there are effective alternative therapies for patients with severe AS. Selection of these surgical methods will be important in the near future. In regard to low operative risk patients especially, not only operative mortality, but also long-tern mortality and morbidity and quality of life should be taken into consideration. It is considered that some comorbidities in AS patients will be revealed to have an impact on surgical outcomes at the time when these surgical methods are selected. In this review, we examine end-stage renal disease on hemodialysis, functional tricuspid regurgitation, and sigmoid septum, and give an outline of what influence SAVR and TAVR have on the surgical outcomes of severe AS patients.

Transcatheter Bioprosthetic Aortic Valve Dysfunction: What We Know So Far

Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical valve replacement for patients with severe aortic stenosis (AS) and increased surgical risk. On the basis of the favorable outcomes of recent randomized clinical trials conducted in intermediate and low risk populations, TAVR is expected in the near future to be offered to patients not only at lower surgical risk, but also with longer life expectancy. In this particular subset, the long-term durability of the bioprosthetic valve is of critical importance. The European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC), and the European Association for Cardio-Thoracic Surgery (EACTS) recently introduced standardized criteria to define structural valve deterioration (SVD) and valve failure of transcatheter and surgical aortic bioprosthesis—this with the aim to generate uniformity in data reporting in future studies assessing long-term durability of aortic bioprosthesis. On this background, the aim of this article is to review the definition, incidence and predictors of transcatheter bioprosthetic valve dysfunction, including structural and non-structural valve deterioration (SVD/NSVD), valve thrombosis, and endocarditis.

Outcomes of Redo Transcatheter Aortic Valve Implantation for Structural Valve Degeneration of Transcatheter Aortic Valve

Background: The outcome of redo transcatheter aortic valve (TAV) implantation (TAVI) is unknown for TAV structural valve degeneration (SVD). This paper reports the initial results of redo TAVI for TAV-SVD in Japanese patients. Methods and Results: Of 630 consecutive patients, 6 (1.0%) underwent redo TAVI for TAV-SVD (689-1,932 days after the first TAVI). The first TAV were 23-mm balloon-expandable valves (BEV, n=5) and a 26-mm self-expandable valve (SEV, n=1). All patients underwent multidetector computed tomography (MDCT) before redo TAVI, which showed first-TAV under-expansion (range, 19.1-21.0 mm) compared with the label size. Two BEV and 4 SEV were successfully implanted as second TAV, without moderate/severe regurgitation or 30-day mortality. One of 2 patients with a BEV-inside-BEV implantation had a high transvalvular mean pressure gradient post-procedurally (34 mmHg) and required surgical valve replacement 248 days after the redo TAVI. This, however, was unnoted in patients with SEV implantation during redo TAVI. Planned coronary artery bypass grafting was concomitantly performed in 1 patient with a small sino-tubular junction and SEV-inside-SEV implantation because of the risk of coronary malperfusion caused by the first TAV leaflets. Five of the 6 patients survived during the follow-up period (range, 285-1,503 days). Conclusions: Redo TAVI for TAV-SVD appears safe and feasible, while specific strategies based on MDCT and device selection seem important for better outcomes.

Aortic stenosis is a risk factor for all-cause mortality in patients on dialysis: a multicenter prospective cohort analysis

Background

Aortic stenosis (AS) is common in patients on dialysis as well as in the general population. AS leads to difficulty with dialysis therapy because of unstable conditions such as intradialytic hypotension due to low cardiac output. However, the precise morbidity rates and risk factors of AS in patients on dialysis are unknown. Moreover, there are no large-scale observational studies regarding the association between AS in patients on dialysis and mortality. Therefore, we will investigate whether morbidity of AS in patients on dialysis is associated with mortality.

Methods

This is a multicenter prospective cohort analysis in the Tokai region of Japan. The 75 participating centers in this study will enroll approximately 2400 patients during 12 months, with or without AS. We started enrollment in July 2017 and will follow patents until June 2023. Transthoracic echocardiography will be performed to evaluate aortic valve. Parameters used for evaluation of aortic valve are mean pressure gradient between left ventricle and ascending aorta, aortic valve area, and maximum aortic jet velocity. We will diagnose AS using the criteria based on the 2014 American Heart Association/ American College of Cardiology Guideline. We will also perform transthoracic echocardiography at 12, 24, 36, 48, and 60 months. Survival prognosis and CV events will be determined at the end of June 2019, 2020, 2021, 2022, and 2023. Development of AS will be also evaluated as new onset or annual change in AS parameters. We will classify patients based on the presence or absence of AS and the stages of AS and will compare outcomes. Study outcomes will include the following: 1) all-cause mortality rates; 2) incidence of cardiovascular (CV) events; 3) CV-related mortality rates; 4) infection-related mortality rates; 5) new onset or development of AS.

Discussion

We will consider the following hypotheses in this study, among others: The prevalence of AS is higher in dialysis patients; new onset and development of AS are associated with factors that are specific for dialysis, such as hyperphosphatemia, hyperparathyroidism, and medication; and outcomes in AS patients are poorer than in patients without AS at baseline.

Trial registration

UMIN000026756, Registered March 29 2017.

Late Survival After Aortic Valve Replacement in Patients With Moderately Reduced Kidney Function

BACKGROUND

The influence of moderately reduced kidney function on late survival after surgical aortic valve replacement (AVR) is unknown. We analyzed survival after AVR in patients with moderately reduced kidney function.

METHODS AND RESULTS

All patients who underwent primary AVR in Sweden 1997-2013 were identified from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register. Patients were categorized according to estimated glomerular filtration rate (eGFR). Of 13 102 patients, 9836 (75%) had normal kidney function (eGFR >60 mL/min per 1.73 m2) and 3266 (25%) had moderately reduced kidney function (eGFR 30-60 mL/min per 1.73 m2). Mean follow-up time was 6.2 years. Mortality was higher in patients with moderately reduced kidney function; 5-, 10-, and 15-year survival was 76%, 48%, and 25% versus 89%, 73%, and 55% (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18-1.38; P<0.001). Patients with moderately reduced kidney function had a nonsignificantly higher risk of major bleeding (HR, 1.18; 95% CI, 1.00-1.39; P=0.051) and a lower risk for aortic valve reoperation (HR, 0.54; 95% CI, 0.38-0.79; P=0.001) compared to those with normal kidney function. In patients with moderately reduced kidney function, survival was similar in those who received bioprostheses compared to those who received mechanical valves (HR, 0.85; 95% CI, 0.70-1.03; P=0.094).

CONCLUSIONS

Moderately reduced kidney function was strongly associated with increased mortality after AVR. These results have important implications for preoperative risk stratification, and suggest that patients with eGFR 30 to 60 mL/min per 1.73 m2 warrant careful observation after AVR.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.

Tissue valves are preferable for patients with end-stage renal disease: an aggregate meta-analysis

BACKGROUND

Valve selection in patients with end-stage renal disease (ESRD) is uncertain. We performed a systematic review and meta-analysis to compare clinical outcome in ESRD patients undergoing valve replacement.

METHODS

We systematically searched multiple databases (2000-October 2015) to identify original studies comparing adverse events between mechanical and biological valve replacement in ESRD patients. End-points studied were: postoperative mortality, bleeding events, need for re-operation, and late survival. A random-effect inverse-variance weighted analysis was performed; event rates are compared as odds ratio (OR and 95% confidence interval) and hazard ratios (HR) for time-to-event data. Mechanical valve and tissue valve replacement were considered as study and control cohorts, respectively.

RESULTS

Fifteen retrospective studies (5523 mechanical and 1600 tissue valve) were included in our meta-analysis. Early mortality was comparable (OR 1.15 [0.77; 1.72]; p = 0.49). The mean follow-up among studies ranged from 1.6-15 years. Bleeding was significantly higher after mechanical valve replacement (OR 2.55 [1.53; 4.26]; p = 0.0003). Structural valve degeneration was present in only 0.6% patients after a tissue valve replacement. Overall survival after valve replacement was poor (median 2.61 years); valve choice did not influence this outcome (pooled HR 0.87 [0.73; 1.04]; p = 0.14).

CONCLUSION

Operative mortality in ESRD patients is comparable between mechanical and tissue valve replacement. Major bleeding episodes are significantly higher after mechanical valve replacement but structural degeneration in tissue valves during the follow-up period is low. Based on the findings from this meta-analysis, we would recommend using tissue valves in patients with ESRD.

Bioprosthetic versus mechanical prostheses for valve replacement in end-stage renal disease patients: systematic review and meta-analysis

BACKGROUND

Patients with end-stage renal disease (ESRD) indicated for dialysis are increasingly requiring cardiac valve surgery. The choice of bioprosthetic or mechanic valve prosthesis for such patients requires careful risk assessment. A systematic review and meta-analysis was performed to assess current evidence available.

METHODS

A comprehensive search from six electronic databases was performed from their inception to February 2015. Results from patients with ESRD undergoing cardiac surgery for bioprosthetic or mechanical valve replacement were identified.

RESULTS

Sixteen studies with 8,483 patients with ESRD undergoing cardiac valve replacement surgery were included. No evidence of publication bias was detected. Prior angioplasty by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery was significantly higher in the bioprosthetic group compared to the mechanical group (16.0% vs. 12.0%, P=0.04); all other preoperative baseline patient characteristics were similar. There was no significant difference in 30-day mortality or all-cause mortality between the two comparisons. Compared with the mechanical group, the frequency of bleeding (5.2% vs. 6.4%, P=0.04) and risk of thromboembolism (2.7% vs. 12.8%, P=0.02) were significantly lower in the bioprosthetic group. There were similar rates of reoperation and valve endocarditis.

CONCLUSIONS

The present study demonstrated that patients with ESRD undergoing bioprosthetic or mechanical valve replacement had similar mid-long term survival. The bioprosthetic group had lower rates of bleeding and thromboembolism. Further studies are required to differentiate the impact of valve location. The presented results may be applicable for ESRD patients requiring prosthetic valve replacement.