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

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Abstract

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.

Section snippets

Material and methods

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

Results

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).

One patient with a mechanical valve required reoperation for prosthetic valve endocarditis (PVE), requiring both aortic (allograft) and mitral (bioprosthesis) valve replacement. However, 4 patients with

Comment

The first report of valve replacement in patients with end-stage renal failure was by Lansing and coworkers in 1968 [5]. In their series, 1 patient with aortic valve endocarditis and another patient with rheumatic mitral regurgitation received Starr-Edwards prostheses (Baxter, Irvine, CA). Both patients underwent successful operations and were discharged from the hospital.

Since that time, there have been many reports of successful valvular operations in patients on dialysis. However, only 2

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