Impact of Renal Failure on Valvular Heart Disease

Patients with abnormal kidney function exhibit both a higher prevalence and an accelerated course of valvular calcification than those in the general population, and this can potentially affect both the aortic and mitral valves. This chapter focuses on valve disease in the setting of chronic kidney disease (CKD), and will discuss pathology, potential prophylaxis, diagnosis, follow-up, and treatment, including considerations involved in surgical and percutaneous management, and post-operative follow-up. Given the rapid course of valvular disease in CKD, it is important to identify valvular pathology promptly in these patients. Transthoracic echocardiography is the modality of choice for the detection and follow-up of valvular heart disease and it is recommend that all dialysis patients be screened within the first 1-3 months of dialysis initiation, once dry weight has been achieved. When compared to those in the general population, patients with CKD experience worse outcomes after valve procedures, both surgical and percutaneous. In severe aortic stenosis (AS), transaortic valve replacement (TAVR) appears to have a better safety profile in patients with CKD when compared to surgical aortic valve replacement (SAVR). A Heart Valve Team should be involved in the selection of a surgical versus percutaneous approach. Regardless of the type of valve intervention selected, patient management should emphasize prevention strategies to minimize kidney injury. The presence of significant mitral annular calcification (MAC) in patients with severe mitral regurgitation (MR) adds technical challenges during mitral valve surgery and thus patients with significant calcification are frequently denied this procedure. The main alternative for these patients is MitraClip. However, despite the fact that kidney disease is highly prevalent among patients undergoing MitraClip, most initial trials assessing this technology have excluded those with advanced CKD. Breaking this trend, the COAPT trial included a large proportion of patients with CKD, and showed reduction of heart failure (HF) hospitalizations and mortality among patients with severe secondary MR and symptomatic HF undergoing MitraClip when compared to those treated with medical therapy alone. More studies with broader renal inclusion criteria are needed to increase awareness, improve diagnosis and treatment of valvular heart disease in patients with CKD and end-stage renal disease (ESRD), and better elucidate the nuances of surgical and percutaneous interventions in this particular population.