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Renal failure after trans-catheter aortic valve implantation

  • Marianna Adamo
    Correspondence
    Corresponding author.
    Affiliations
    Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Brescia, Italy

    Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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  • Salvatore Curello
    Affiliations
    Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Brescia, Italy

    Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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  • Marco Metra
    Affiliations
    Cardiothoracic Department, ASST Spedali Civili di Brescia University of Brescia, Brescia, Italy

    Department of Medical Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Published:August 07, 2020DOI:https://doi.org/10.1016/j.ejim.2020.08.002
      Trans-catheter aortic valve implantation (TAVI) is by now considered the treatment of choice in patients with severe and symptomatic aortic stenosis deemed at prohibitive or high surgical risk. However, recent evidence has led to broaden TAVI indication to intermediate and low-risk patients [
      • Indolfi C
      • Bartorelli AL
      • Berti S
      • et al.
      Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian society of cardiology and GISE.
      ]. This implies better technologies and minimizing acute complications such as pacemaker implantation, vascular injury, renal failure and radiological exposure [
      • Indolfi C
      • Bartorelli AL
      • Berti S
      • et al.
      Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian society of cardiology and GISE.
      ,
      • Biasco L
      • Pedrazzini G
      • De Backer O
      • et al.
      Radiological exposure of patients undergoing transcatheter aortic valve implantation in contemporary practice.
      ].
      Sgura et al pointed out the prognostic impact of acute kidney injury (AKI) on early mortality after balloon-expandable TAVI, especially in patients with severe chronic kidney disease (CKD) [
      • Sgura FA
      • Arrotti S
      • Magnavacchi P
      • et al.
      Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation.
      ]. Both AKI and renal function during hospitalization had been reported as predictors of poor outcome in either TAVI or non-TAVI setting [
      • Gargiulo G
      • Sannino A
      • Capodanno D
      • et al.
      Impact of postoperative acute kidney injury on clinical outcomes after transcatheter aortic valve implantation: a meta-analysis of 5,971 patients.
      ,
      • Tarro Genta F
      • Tidu M
      • Corbo P
      • et al.
      Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation.
      ,
      • Campanile A
      • Castellani C
      • Santucci A
      • et al.
      Predictors of in-hospital and long-term mortality in unselected patients admitted to a modern coronary care unit.
      ,
      • Topaz G
      • Gharra W
      • Eisen A
      • et al.
      Impaired renal function is associated with adverse outcomes in patients with chest pain discharged from internal medicine wards.
      ]. However, the authors need to be congratulated for dealing with an important issue about the management of patients undergoing an increasingly widespread treatment.
      We recently reported similar results in a larger multicentre population undergoing self-expanding TAVI with longer follow-up [
      • Adamo M
      • Provini M
      • Fiorina C
      • et al.
      Interaction between severe chronic kidney disease and acute kidney injury in predicting mortality after transcatheter aortic valve implantation: Insights from the Italian clinical service project.
      ]. Stratifying our population by the presence of severe pre-procedural CKD and post-procedural AKI, similarly to Sgura et al, we observed that patients having severe CKD and who developed AKI definitely had the worst survival rate. These results were confirmed also at five-year follow-up [
      • Adamo M
      • Provini M
      • Fiorina C
      • et al.
      Interaction between severe chronic kidney disease and acute kidney injury in predicting mortality after transcatheter aortic valve implantation: Insights from the Italian clinical service project.
      ].
      Consistently, Sgura et al observed a non-significant trend towards a 3-fold increased adjusted risk of 30-day mortality in patients without CKD who developed AKI, and a 9-fold increased adjusted risk of 30-day mortality in patients with both CKD and AKI, compared to those without CKD and without AKI [
      • Sgura FA
      • Arrotti S
      • Magnavacchi P
      • et al.
      Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation.
      ].
      In our population, after adjustment for possible confounders, we did not find any interaction between severe CKD and post-procedural AKI in predicting either 30-day or 1-year mortality after TAVI [
      • Adamo M
      • Provini M
      • Fiorina C
      • et al.
      Interaction between severe chronic kidney disease and acute kidney injury in predicting mortality after transcatheter aortic valve implantation: Insights from the Italian clinical service project.
      ]. This would suggest that, being mortality predicted by AKI regardless CKD, both patients with and without severe CKD should be monitored and possibly treated to prevent AKI and improve outcome. We believe that this aspect is extremely important since the majority of patients who developed AKI after TAVI did not have severe CKD before the procedure (84% the study by Sgura et al and 65% in our population).
      Definitely, severe CKD remains an important predictor of post-procedural AKI. In our cohort, severe CKD as well as contrast medium and general anaesthesia, were independently associated with an increased risk of AKI [
      • Adamo M
      • Provini M
      • Fiorina C
      • et al.
      Interaction between severe chronic kidney disease and acute kidney injury in predicting mortality after transcatheter aortic valve implantation: Insights from the Italian clinical service project.
      ]. Sgura et al found contrast medium and trans-apical access as predictors of AKI in their population [
      • Sgura FA
      • Arrotti S
      • Magnavacchi P
      • et al.
      Kidney dysfunction and short term all-cause mortality after transcatheter aortic valve implantation.
      ].
      Trans-apical approach as well as general anaesthesia can lead to AKI due to renal hypoperfusion. In this regard, even if approaches alternative to trans-femoral have been reported as safe and effective [
      • Anselmi A
      • Tomasi J
      • Giardinelli F
      • Bedossa M
      • Rosier S
      • Verhoye JP
      Safety and effectiveness of the transsubclavian approach for transcatheter aortic valve implantation with the 14-F CoreValve Evolut R Device.
      ,
      • Adamo M
      • Fiorina C
      • Curello S
      • et al.
      Role of different vascular approaches on transcatheter aortic valve implantation outcome: a single-center study.
      ], trans-femoral approach always represents the first choice in TAVI candidates to avoid complications, including AKI.
      Finally, we would like to point out that patients with severe pre-procedural CKD who did not develop AKI showed an improvement of renal function after TAVI likely mediated by increased cardiac output after the procedure [
      • Adamo M
      • Provini M
      • Fiorina C
      • et al.
      Interaction between severe chronic kidney disease and acute kidney injury in predicting mortality after transcatheter aortic valve implantation: Insights from the Italian clinical service project.
      ].
      In conclusion, AKI remains a negative prognostic factor in patients undergoing TAVI being associated with an increased risk of short-term mortality. Its impact on mortality does not seem to be influenced by severe pre-procedural CKD. CKD, as well as contrast medium administration, trans-apical approach and general anaesthesia, remain important predictors of AKI post-TAVI. Strategies to prevent AKI should definitely be adopted in patients with severe CKD, but they should be extended also to those with moderately reduced or normal renal function, who represent the majority of population experiencing AKI after TAVI.

      Declaration of Conflict of Interest

      The authors do not have conflicts of interest to report

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