V DKDIGO IN CKD/ESRD...frequently with mitral regurgitation and mitral stenosis KDIGO. VALVULAR...

VALVULARDISEASEINCKD/ESRD

MohamedMarwanCardiologistUniversityHospitalErlangen

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DISCLOSURES

•  SpeakerHonorariaSiemensHealthineersandEdwardsLifesciences

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CONSIDERATIONS

•  Differencescomparedtonormalpopulation?

•  InfluenceofCKDonnaturalhistoryofvalvulardisease

•  Diagnostics

•  Prevention•  Challengesininterventional/surgicaltreatment

•  ValvulardiseaseandoralanticoagulationinthesettingofCKD/ESRD

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CARDIOVASCULARDISEASEINCKD/ESRDPATIENTS

•  Twotofourtimeslikelihoodofcardiovasculardiseasecomparedtogeneralpopulation

•  LeadingcauseofMortalityinthiscohort

•  Pathophysiologymainlyrelatedtovascularandvalvularcalcifications

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JASN2017

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•  949119patients

Lancet2013

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•  InteractionHeartandKidney

Lancet2013

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VALVULARAFFECTIONINCKD/ESRDPATIENTS

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•  Primarilytriggeredbyvalvularcalcification

•  Leftsidedvalveaffectionduetohighermechanicalstress

•  Aorticpositioncausingpredominantlystenosis

•  Mitralpositioncausingleafletrestriction/calcificationpresentingmorefrequentlywithmitralregurgitationandmitralstenosis

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•  ASCalcification

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•  MR Calcificationoftheannulus,mitralvalveapparatus,chordae causingprimaryMR

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•  MR Calcificationoftheannulus,mitralvalveapparatus,chordae causingprimaryMR

PoorLVfunctionsduetoconcomitantCAD,secondaryMRKDIGO


•  Rightsidedheartmorecommonlyaffectedinthecontextofpulmonaryhypertensionduetoleftsidedlesion,kidneydiseaseandvolumestatus

EHJ2013

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AORTICVALVEAFFECTIONINCKD/ESRDPATIENTS

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•  Increasedcalciumdeposition

•  ThenaturalhistoryofdiseaseisdifferentthenASinnon-CKDpopulation:acceleratedprogression,youngerpresentation

AMJCardiol2016

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•  Calciumisrelatedtooutcome


JACC2014

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MITRALVALVEAFFECTIONINCKD/ESRDPATIENTS

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•  Mitralannularcalcificationwithvaryingseveritycausingregurgitationorstenosis

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MITRALVALVEAFFECTIONINCKD/ESRDPATIENTS•  EmbolicmanifestationsespeciallyinsevereformsofMAC(Caseous

mitralvalvecalcification)

2012 2018

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•  MACassociatedwithCVDmorbidityandmortality

JACC2014


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PREVALENCEOFLEFT-SIDEDVALVULARLESIONSINCKD•  Longitudinaldatafrom1999to2013,78059patients,30%CKD

JAHA2017

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PREVALENCEOFLEFT-SIDEDVALVULARLESIONSINCKD•  Longitudinaldatafrom1999to2013,78059patients,30%CKD

JAHA2017

ModerateandsevereMRwithCKD ModerateandsevereASwithCKD

•  Theprevalenceofatleastmildleft-sidedvalvulardiseaseintheCKDgroupwasmorethandoublethatinthenon-CKD

•  The5-yearmortalityrateofpatientswithatleastmildAS/MRwas>50%greaterintheCKDgroupthaninthenon-CKDgroup

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DIAGNOSTICIMAGINGINCKD/ESRDPATIENTS

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DIAGNOSTICIMAGINGINCKD/ESRDPATIENTS

•  Clearlyadomainofechocardiography

•  CT:transcatheterintervention

•  MRI:onlyaorticregurgitation

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PREVENTIVESTRATEGIESINCKD/ESRDPATIENTS

•  Clusteringofcardiovascularriskfactorsinthispatientcohort

•  Commondiseasepathwaysforkidneyandcardiovascular•  disease

•  Whetherstrictcontrolofriskfactorshasthesamebenefit/effectinCKDandnon-CKDisnotentirelyclear

•  Screeningforvalvularlesionsinsymptomaticpatients

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PREVENTIVESTRATEGIESINCKD/ESRDPATIENTS

•  STATINSforAS:havenotprovedbeneficialsofaringeneralpopulationandDatacanprobablybeextrapolatedtoCKD

NEJM2005

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TREATMENTOFVALVULARDISEASE

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TREATMENTOFVALVULARDISEASE

•  Datagap:Insufficientdataforguidelinesconcerningmanagementandfollow-upinthesepatients

•  Moretreatmentoptionswiththeadventofpercutaneouscatheterinterventions

•  BetterdefinitionofwhichCKD/ESRDpatientswouldbenefitmostandwhichtimepointfromintervention

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•  SurgeryforAorticstenosis

•  3266patientswithmoderateCKD

TREATMENTOFAORTICSTENOSIS

JAHA2016

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•  TAVI/TAVRforAorticstenosisinGermany

28716patientsPredominantlyWomenHigherrateofComorbidities

TREATMENTOFAORTICSTENOSIS

CJASN2017

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TAVI/TAVRVERSUSSURGICALREPLACEMENT

ClinCardiol2017

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TAVI/TAVRVERSUSSURGICALREPLACEMENT

Mortality2.9%vs.7.1%(p=0.09)

•  Propensityscorematchedpatients(170)

AmJCardiol2017

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VALVEDURABILITY

Heart2017

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VALVEREPLACEMENTINCKD

•  545paDents

JournalofThoracicandCardiovascSurg2014

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VALVESURGERYINRENALTRANSPLANTPATIENTS

•  1335transplantpaDents

•  75%AVR

•  20%MV

•  5%combined

•  In-hospitaloverallmortality14%

•  2-yearmortality40%

•  TissuevalvespreferredCirc2010

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TAVI/TAVRINRENALTRANSPLANTPATIENTS

•  8transplantpaDents

•  Allaliveat1year

•  RetrospecDvecomparisonto18paDentssentforAVR,1-yearmortality16.7%

IntJCardiol2018

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MITRALVALVESURGERY

•  Duetoanatomicalconsiderationswithexcessivecalcification,mitralvalverepairoftennotpossible

•  SimilartoAVR,CKD/ESRDaffectsoutcomeaftersurgery

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MITRALVALVESURGERY

•  Duetoanatomicalconsiderationswithexcessivecalcification,mitralvalverepairoftennotpossible

•  SimilartoAVR,CKD/ESRDaffectsoutcomeaftersurgery•  Repairattemptedlessfrequently

•  Repairsuccessequallylikely

•  Repairvs.Replacementdidnotaffectshorttermoutcome

JTCVS2014

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PERCUTANEOUSTREATMENTOFMRINCKD/ESRD

EurointervenFon2016

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PERCUTANEOUSTREATMENTOFMRINCKD/ESRD

JACC2018

•  30daymortality25%•  1yearmortality53%

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CHOICEOFVALVEINESRDPATIENTS

JCardSurg2016

•  5523mechanicalvalves•  1600tissuevalves

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VALVECOMPLICATIONS

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PROSTHETICVALVEENDOCARDITIS

AnnThoracicSurgery2016

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AmHeartJournal2016

•  38foldincreasedriskofIEcomparedtoageandgendermatchedpopulation

•  IncreasedriskamongpatientswithnoAVfistula KDIGO


Circ2013

•  PredominantlyStaphylococcusEndocarditis

•  MortalityPredictors:•  Age•  DMasacauseofESRD•  Surgeryduringindex

hospitlization•  Staph•  Dysrhythmia

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ORALANTICOAGULATIONINVALVULARDISEASE

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•  CKDpatientsaremoreproneforAF,OAKformechanicalvalves

•  Moreproneforbleeding

•  MoreoptionsforOAC(apartfrommechanicalValves)

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•  PatientsonRRT:nodatafornewOAC,VKA

•  Generally,DOACarenotrecommendedbelowGFR30ml/min/

•  UseofDOACinAFpatientswithmoderatelyreducedGFRhasbeenshownin

subgroupsfromRCTStobesafeandassociatedwithlessbleedingcomparedtoVKA

•  PatientswithCKDonVKAshowless‘TimeinTherapeuticRange`

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•  PatientsonRRT:nodatafornewOAC,VKA

•  Generally,DOACarenotrecommendedbelowGFR30ml/min/

•  UseofDOACinmoderatelyreducedGFRhasbeenshowninsubgroupsfromRCTStobesafeandassociatedwithlessbleedingcomparedtoVKA

IntJCardiol2016

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CONCLUSIONSI

•  ValvulardiseaseinCKD/ESRDiscommonpredominantlycausedbyexcessivecalcification

•  Left-sidedvalvulardisease(AS,MR)issignificantlyhigherinCKDcomparedtonon-CKDpopulationandisassociatedwithhighermortality

•  Forbothsurgicalandinterventionaltreatment,CKDpatientsshowworseoutcomecomparedtonon-CKDpopulations

•  TAVI/TAVRinthecontextofASinCKDseemstobeassociatedwithbetteroutcomecomparedtosurgery(Mortality,AKI,HospitalStay)

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CONCLUSIONSI


•  Left-sidedvalvulardisease(AS,MR)issignificantlyhigherinCKDcomparedtonon-CKDpopulationandisassociatedwithworseoutcome



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CONCLUSIONSI


•  Left-sidedvalvulardisease(AS,MR)issignificantlyhigherinCKDcomparedtonon-CKDpopulationandisassociatedwithhighermortality



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CONCLUSIONSII

•  Surgicalvalvularreplacementwithtissuevalvesandmechanicalvalvesshowcomparableoutcomewithlessbleedingfortissuevalves

•  ProstheticvalveendocarditisriskishigherinESRD,highsurgicalmortality

•  Interventionaltreatmentofmitralvalvediseaseisstillintheearlyeraevenvonnon-CKDcohorts

•  Dataforrightsideddiseasearescarce

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THANKYOU

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V DKDIGO IN CKD/ESRD...frequently with mitral regurgitation and mitral stenosis KDIGO. VALVULAR...

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