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      Management of Aortic Stenosis in Patients With End-Stage Renal Disease on Hemodialysis

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          Abstract

          Background:

          Patients with end-stage renal disease on hemodialysis (ESRD-HD) and aortic stenosis have poor prognosis. The role of transcatheter aortic valve replacement (TAVR) in this high-risk population is debated.

          Methods:

          We compared the outcomes among ESRD-HD Medicare beneficiaries who were managed with TAVR, surgical AVR (SAVR), or conservative management for aortic stenosis between 2015 and 2017, using overlap propensity score weighting analysis to control for differences in treatment assignment. The primary outcome was all-cause mortality and was compared between treatment groups as well as to age-sex matched mortality for ESRD-HD in the US population. Secondary outcomes included trend of heart failure hospitalizations.

          Results:

          A total of 8107 ESRD-HD patients with aortic stenosis were included, 4130 (50%) underwent TAVR, 2565 (31.6%) underwent SAVR, and 1412 (17.4%) were managed conservatively. TAVR patients had more comorbidities and higher frailty compared with the other 2 groups. Thirty-day mortality was lower with TAVR compared with SAVR (4.6% versus 12.8%, P <0.01). After a median follow-up of 465 days (interquartile range, 261–759), on overlap propensity score weighting analysis, there was no difference in mortality between TAVR and SAVR (adjusted hazard ratio, 1.02 [95% CI, 0.91–1.15], P =0.7), and mortality was lower with TAVR compared with conservative management (adjusted hazard ratio, 0.53 [95% CI, 0.47–0.60], P <0.001). Standardized mortality ratios with TAVR, SAVR, and conservative management compared with age-sex matched ESRD-HD US population were 1.24, 1.27, and 1.83, respectively. The rate of heart failure admissions declined after TAVR (incidence rate ratio, 0.55 [95% CI, 0.48–0.62], P <0.001) and SAVR (incidence rate ratio, 0.76 [95% CI, 0.65–0.88], P <0.001).

          Conclusions:

          In ESRD-HD patients with aortic stenosis, mortality was lower in the short-term with TAVR compared with SAVR but comparable in the mid-term. AVR is associated with an improvement in survival and reduction in heart failure hospitalizations compared with conservative management.

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          Most cited references14

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          Sensitivity Analysis in Observational Research: Introducing the E-Value.

          Sensitivity analysis is useful in assessing how robust an association is to potential unmeasured or uncontrolled confounding. This article introduces a new measure called the "E-value," which is related to the evidence for causality in observational studies that are potentially subject to confounding. The E-value is defined as the minimum strength of association, on the risk ratio scale, that an unmeasured confounder would need to have with both the treatment and the outcome to fully explain away a specific treatment-outcome association, conditional on the measured covariates. A large E-value implies that considerable unmeasured confounding would be needed to explain away an effect estimate. A small E-value implies little unmeasured confounding would be needed to explain away an effect estimate. The authors propose that in all observational studies intended to produce evidence for causality, the E-value be reported or some other sensitivity analysis be used. They suggest calculating the E-value for both the observed association estimate (after adjustments for measured confounders) and the limit of the confidence interval closest to the null. If this were to become standard practice, the ability of the scientific community to assess evidence from observational studies would improve considerably, and ultimately, science would be strengthened.
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            Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients.

            Previous trials have shown that among high-risk patients with aortic stenosis, survival rates are similar with transcatheter aortic-valve replacement (TAVR) and surgical aortic-valve replacement. We evaluated the two procedures in a randomized trial involving intermediate-risk patients.
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              Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients

              Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk.
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                Author and article information

                Contributors
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                Journal
                Circulation: Cardiovascular Interventions
                Circ: Cardiovascular Interventions
                Ovid Technologies (Wolters Kluwer Health)
                1941-7640
                1941-7632
                August 2020
                August 2020
                : 13
                : 8
                Affiliations
                [1 ]Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City (A.M., P.A.H., J.D.R., S.P., M.V.-S.).
                [2 ]Heart and Vascular Institute, Cleveland Clinic Foundation, OH (M.Y.D., S.K.).
                [3 ]Cardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, RI (M.S.).
                [4 ]Division of Cardiology, Baylor College of Medicine, Houston, TX (H.J.).
                [5 ]Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center (M.V.-S.).
                Article
                10.1161/CIRCINTERVENTIONS.120.009252
                32772570
                c6edca4a-8c25-4c19-b22c-540440274a26
                © 2020
                History

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