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Ann Thorac Surg 2000;70:438-441
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Cardiac valve replacement in patients on dialysis: influence of prosthesis on survival

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Smedira, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave/F25, Cleveland, OH 44195
e-mail: smedirn{at}ccf.org

	Abstract

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Background. Mechanical valves have been recommended for patients on dialysis because of purported accelerated bioprosthesis degeneration. This study was undertaken to determine time-related outcomes in dialysis patients requiring cardiac valve replacement.

Methods. From 1986 to 1998, 42 patients on chronic preoperative dialysis underwent valve replacement; 17 received mechanical valves and 25 received bioprostheses. Age was similar in both groups: 54 ± 18.5 years (mechanical) and 59 ± 15.5 years (bioprosthetic, p = 0.4). Sites of valve replacement were aortic (27), mitral (11), and aortic and mitral (4). Follow-up was 100% complete.

Results. Survival at 3 and 5 years was 50% and 33% after mechanical valve replacement, and 36% and 27% after bioprosthetic valve replacement (p = 0.3). Four patients with bioprostheses required reoperation: 3 for allograft endocarditis and 1 at 10 months for mitral bioprosthesis degeneration. One patient who received a mechanical valve required reoperation.

Conclusions. Prosthetic valve-related complications in patients on dialysis were similar for both mechanical and bioprosthetic valves. Because of the limited life expectancy of patients on dialysis, bioprosthesis degeneration will be uncommon. Therefore, surgeons should not hesitate to implant bioprosthetic valves in these patients.

	Introduction

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Classic surgical teaching states that "the longevity of bioprosthetic heart valves is substantially reduced by dialysis dependency" and that patients on dialysis who require valve replacement should, therefore, have mechanical valves implanted [1]. It has long been believed that bioprosthetic valves undergo accelerated calcification in patients with end-stage renal disease, likely as a result of derangements in calcium-phosphate metabolism. However, there are little data to support this contention.

Dialysis became widely available in 1972 with an amendment to the Social Security Act that provided Medicare coverage to patients with end-stage renal disease. Despite improvements in dialysis methodology and management of electrolyte imbalances, dialysis dependency still carries a 25% annual mortality [2]. For patients 55 to 64 years old, the 3- and 5-year survivals from the time of initiation of dialysis are approximately 52% and 33%, respectively [3]. There are currently more than 200,000 patients on dialysis in the United States; it is projected that by the year 2010 there will be 350,000 such patients in this country [2]. With a prevalence of approximately 8% per year, the number of dialysis patients requiring valve operation is likely to increase [4].

Given the poor long-term survival of dialysis patients, we reasoned that patients receiving bioprostheses may die before valve failure occurs. Further, both the anticoagulation necessary for dialysis and the platelet dysfunction associated with renal failure could predispose these patients to bleeding complications, making warfarin sodium undesirable. For these reasons, bioprosthetic valves may be a suitable option for these patients. Therefore, the purpose of this study was to analyze our experience with valve replacement in patients on dialysis in order to formulate guidelines for choice of valvular prosthesis.

	Material and methods

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Using the prospective Cardiovascular Information Registry, we identified 8,185 patients undergoing aortic or mitral valve replacement at The Cleveland Clinic Foundation from 1986 to 1997. Of these, 42 patients had end-stage renal disease on chronic preoperative dialysis. No patients were excluded.

The etiologies of renal failure were hypertension (n = 6), diabetes mellitus (n = 8), polycystic disease (n = 5), and interstitial nephritis (n = 10). In 13 patients the etiology of renal failure was unknown. Eleven patients required valve replacement for degenerative disease, 7 for rheumatic disease, and 12 for endocarditis. In the remaining 12 patients, no specific etiology of the valve disease could be elucidated from the patients’ charts.

Seventeen patients received mechanical valves and 25 received bioprosthetic valves. Mean age between the groups was similar: 54 ± 18.5 years compared with 59 ± 15.5 years (p = 0.4), respectively. Of the patients receiving bioprostheses, 17 were porcine xenografts and 8 were cryopreserved allografts (Cryolife, Kennesaw, GA). During the first 4 years of the experience (1986 through 1989), 4 patients each received bioprostheses and mechanical valves. From 1990 through 1993, 7 received bioprostheses and 6 mechanical valves. In the last 4 years, 14 received bioprostheses and 7 mechanical valves. Aortic valve replacement was performed in 27 patients, mitral valve replacement in 11, and combined aortic and mitral valve replacement in 4 (Table 1).

The status of every patient was ascertained by telephone contact with patient or family, unless complete details of the patient’s course until demise was documented in the institutional medical records. Follow-up was complete for all patients. For patients receiving bioprostheses, follow-up extended to 10 years, with mean survival of living patients 2.3 ± 1.2 years (median 1.9). For those receiving a mechanical prosthesis, follow-up extended to 9 years, with mean survival of living patients 3.4 ± 2.5 years (median 2.7).

Time-related survival and freedom from reoperation, bleeding, thromboembolism, or infection were estimated by the Kaplan-Meier method. Estimates are accompanied by 95% confidence intervals (CI). They were compared using the log-rank test.

	Results

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There were no operative deaths. The 3-year survival for patients receiving bioprostheses was 36% (CI, 16% to 56%) and for those receiving mechanical valves it was 50% (CI, 25% to 75%). At 5 years, survival was 27% (CI, 5% to 49%) and 33% (CI, 2% to 65%), respectively (p = 0.3) (Fig 1).

View larger version (15K): [in this window] [in a new window]   Fig 1. Survival of dialysis patients receiving either mechanical (Mech) or bioprosthetic (Bio) valves. The solid line represents estimates for patients receiving a bioprosthesis and the dashed lines a mechanical prosthesis. The numbers at risk at yearly time intervals are shown.

The patient requiring reoperation for valvular degeneration was a 44-year-old diabetic man who had had a Carpentier-Edwards (Baxter, Irvine, CA) porcine valve placed in the mitral position for endocarditis. He required reoperation 10 months after his initial operation and was found to have calcification of, and regurgitation through, his bioprosthesis. A second Carpentier-Edwards porcine valve was placed in the mitral position; the patient died 7 months later from sepsis.

The incidence of cerebrovascular accident was low: 2 patients with mechanical valves and 1 patient with a bioprosthetic valve had strokes. Eight patients (5 mechanical valve and 3 bioprosthetic valve recipients) had bleeding episodes requiring blood transfusion: 7 had gastrointestinal bleeding and 1 patient with a mechanical valve had significant epistaxis. All bleeding episodes occurred early; 1- and 5-year freedom from hemorrhage was 81% for patients receiving bioprostheses and 76% for mechanical valve recipients (p = 0.5) (Fig 2). Whereas all of the mechanical valve recipients were maintained on Coumadin, none of the patients with bioprostheses that bled received anticoagulation therapy.

View larger version (13K): [in this window] [in a new window]   Fig 2. Freedom from hemorrhage in dialysis patients receiving either mechanical (Mech) or bioprosthetic (Bio) valves. The depiction is formatted as in Figure 1.

	Comment

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Since that time, there have been many reports of successful valvular operations in patients on dialysis. However, only 2 groups have addressed the issue of dialysis-related accelerated calcification of bioprosthetic valves [6–11]. In 1978, Lamberti and colleagues [12] reported 2 cases of calcification of porcine heterografts, 1 of which was in a patient on chronic hemodialysis. This patient died from sepsis and endocarditis 15 months after valve replacement.

Lucke and coworkers [13] reviewed their experience with 19 patients on long-term dialysis undergoing valve replacement from 1979 to 1994. Nine patients received bioprosthetic valves and 10 received mechanical valves. At a mean follow-up of 32 months, no patient required reoperation for bioprosthesis degeneration; however, patients receiving mechanical valves had a higher incidence of thromboembolism and bleeding.

Like Lucke’s group, we found accelerated calcification of bioprostheses to be uncommon in patients on preoperative dialysis. The incidence of major bleeding and stroke in the current series was not significantly different between the mechanical valve and bioprosthesis groups. However, other large series of valve replacement have confirmed the disadvantage of chronic Coumadin therapy [14].

Byrne and colleagues [3] reported the survival of all Medicare patients with end-stage renal failure in the United States from 1982 to 1987. In this study of over 95,000 patients, the average survival of a patient between 55 and 65 years old, from the time dialysis was started, was 52% at 3 years and 33% at 5 years. In the current series of dialysis patients undergoing valve replacement, overall mean survival was 23 weeks from the time of operation. This finding suggests that the life expectancy among these patients is so poor as to not affect the choice of valvular prosthesis in most patients. Specifically, there is little need for a prosthetic valve that will endure more than a few years in this population.

We conclude the following: (1) Valve replacement in dialysis patients is not only feasible but does not seem to decrease survival of these patients when compared with that of the overall population of patients on dialysis. (2) Despite anecdotal reports, accelerated calcification of bioprostheses in patients on dialysis is uncommon. Although these conclusions are based on a single clinical study of a limited patient population, this study has been the largest to date to address this issue.

Given the lack of a clinical difference in morbidity or survival following either mechanical or bioprosthetic valve replacement, and given the overall dismal survival of dialysis patients in general, we believe that concern for accelerated calcific bioprosthesis degeneration should not play a role when choosing a valve for patients on dialysis. Rather, other variables such as patient age, gender, level of activity, and presence of infection should dictate valve selection, and not the diagnosis of end-stage renal failure.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard J. Kaplon Delos M. Cosgrove, III A. Marc Gillinov Bruce W. Lytle Eugene H. Blackstone Nicholas G. Smedira Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kaplon, R. J. Articles by Smedira, N. G. Search for Related Content PubMed PubMed Citation Articles by Kaplon, R. J. Articles by Smedira, N. G.