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Ann Thorac Surg 1997;64:129-132
© 1997 The Society of Thoracic Surgeons
Department of Surgery, Duke University Medical Center, Durham, North Carolina
Accepted for publication January 24, 1997.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. A retrospective review was performed on 19 consecutive patients from our institution with end-stage renal disease on chronic peritoneal or hemodialysis undergoing aortic (n = 12), mitral (n = 5), or aortic-mitral (n = 2) valve replacement.
Results. The 9 biological and 10 mechanical valve patients had similar ages (56.5 versus 56.6 years) and cardiovascular risk factors. The overall estimated Kaplan- Meier survival was 60% ± 12% at 12 months and 42% ± 14% at 60 months. Mechanical valve patients had a significantly higher rate of postoperative cerebrovascular accidents or bleeding complications (10/10 versus 0/9; 
2 = 17.0; p < 0.001). No subsequent reoperations were required for biological valve failure at a mean follow-up of 32 ± 53 months.
Conclusions. These results demonstrate that in patients with end-stage renal disease, use of mechanical valves is associated with significant risk of complications, whereas biological valve failure from prosthetic dysfunction is unusual. Overall survival is poor in both groups of patients. Therefore, preference should be given to biological valve instead of mechanical valve prostheses in patients on chronic renal dialysis.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Patients with end-stage renal disease (ESRD) are at increased risk for complications involving their native valve. Undergoing frequent arteriovenous access for hemodialysis may increase the risk for endocarditis [1, 2]. In 1990, more than 52% of patients who received chronic dialysis were 55 years of age or older [3]. Senile calcification of valves, a normal process with aging, may be accelerated in patients with ESRD [2, 4].
The traditional teaching is that biological valves (BV) will undergo premature degeneration due to accelerated calcification in patients with ESRD, therefore mechanical valves (MV) are favored in patients requiring valve replacement by most cardiothoracic surgeons [5–7]. However, some surgeons use biological valves in selected patients [6, 7]. Because several dialysis patients who underwent MV replacement at our institution had bleeding complications, BV have recently been used more frequently. The purpose of this report is to evaluate the results of valve replacement in patients on chronic dialysis and to compare MV with BV replacement.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Biological-valve replacement patients were given 325 mg aspirin daily unless contraindicated, and no warfarin sodium (Coumadin; DuPont Pharmaceuticals, Wilmington, DE) was used. Mechanical-valve replacement patients were anticoagulated with Coumadin alone unless they developed a contraindication to anticoagulation. Several patients had to have their Coumadin administration stopped. Our current policy in these ESRD patients undergoing MV replacement is to maintain the international normalized ratio at a target range of 2.0 to 3.0, although the actual Coumadin dose was at the discretion of the individual surgeon.
Demographic and operative data were collected from retrospective review of the patients' medical records and operative data base. Symptomatic status for congestive heart failure was rated using the classification of the New York Heart Association. Each patient's family was contacted by telephone to elaborate on the patient's dialysis history and to obtain any additional information on complications or cause of death. Follow-up was complete on 78% of patients and no patients underwent renal transplantation during the follow-up period.
There has been a recent trend favoring biological valves, with 5 of the 9 BV replacements performed during the final 2 years of the study. The preoperative age and cardiovascular risk factors did not differ significantly between the BV and MV groups. Each group had more patients on hemodialysis than peritoneal dialysis. There was no significant difference between BV and MV groups in baseline congestive heart failure class or ejection fraction (Table 1
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2goodness of fit test. All data are presented as means ± standard deviation unless otherwise stated. |
Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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). It should be noted that a large number of patients died during the first 12 months after operation.
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). Bleeding complications were found in patients receiving MV only. The arteriovenous fistula or polytetrafluoroethylene graft (n = 4), gastrointestinal tract (n = 3), and brain were the most common locations of clinically significant bleeding. Several patients had to have their Coumadin administration stopped at least temporarily. These complications were not felt to be because of poor patient compliance or inadequate monitoring. Bleeding at the site of the arteriovenous fistula or polytetrafluoroethylene graft occurred in 4 of 7 MV patients on hemodialysis and often required dialysis through an indwelling venous catheter. These catheters minimize the risk of bleeding associated with starting and stopping hemodialysis but are associated with a much higher infection rate, endocarditis rate, and complication rate than either arteriovenous fistulas of polytetrafluoroethylene grafts [8]. The average time of onset for bleeding complications was 12.6 months, with a range of 1 to 57 months. There were no bleeding complications in the patients receiving BV (Fig 2).
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). All patients with MV experienced a bleeding complication or had a stroke by 50 months.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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As the population ages, the incidence of degenerative valvular disease in patients with normal renal function appears to have increased [9]. This phenomenon of senile valvular degeneration is generally in patients who are in their 70s and 80s. Our series had several patients with a mean age closer to 60 who presented with degenerative or senile aortic valvular disease. It may be that degenerative valvular disease occurs earlier in the face of chronic renal disease.
As patients receiving dialysis age, and with advances in medical therapy, more of these dialysis patients will require valve replacement and coronary artery bypass grafting [10]. Often moderate to severe aortic stenosis is found in patients with symptomatic coronary disease. Three patients in our series had a combined procedure for coronary artery disease and degenerative aortic valvular disease. The decision to replace the aortic valve at the time of coronary revascularization is a separate and sometimes controversial subject and is clearly determined based on the specific hemodynamics and the patient's projected long-term survival.
Endocarditis was the reason for valve replacement in 4 of the 19 patients in this series. Although this is a somewhat higher percentage than in patients with normal renal function, none of the cases could be directly linked to dialysis. Our patients undergoing dialysis do not currently receive prophylactic antibiotics, even following valve replacement.
The durability of the BV in the patient with normal renal function has been well established. At 10 years, the estimated freedom from structural valve deterioration in a recent study was 85% for aortic and 78% for mitral valve replacement [11]. The general concern that BV will undergo premature degeneration in patients with ESRD owing to calcification is based on a report by Lamberti and associates from 1979 [4]. In this article, they described 2 patients with premature calcification of porcine mitral valves following mitral valve replacement. There are no reports in the literature of premature biological aortic valve degeneration in a patient with ESRD. One of the patients in our study had degeneration of a biological aortic valve, but it was more than 10 years after operation. Biological valves are favored in older patients with normal renal function because there is an increased incidence of bleeding associated with anticoagulation and thrombotic complications [12]. End-stage renal disease is a known major risk factor for major bleeding in patients treated with Coumadin [13]. Furthermore, BV will generally have better durability in older patients, and BV survival generally outlasts the patient's survival [14]. With the increased incidence of bleeding and thrombotic complications demonstrated in patients with ESRD during this study and the short survival time of these patients, BV replacement has clear advantages.
The type of valve chosen for these patients should be individualized based on the valve being replaced, the age of the patient, and the expected long-term survival. For mitral valves, valve repair, if possible, is usually the best option [15]. Mechanical valves, especially mitral, should be considered in young and otherwise healthy ESRD patients with the understanding by the patient and the family that MV patients are at considerably higher risk for complications from bleeding or thrombosis. End-stage renal disease patients who are older and patients with a relative short life expectancy (most patients with ESRD) should be considered as candidates for BV.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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