1. TAVR in Patients With Chronic Kidney Disease
Fadi Matar, MD, FSCAI. FACC
Associate Professor of Medicine. University of South Florida
Medical Director, Cardiac Cath Lab. Tampa General Hospital

2. Fadi Matar, MD, FSCAI, FACC
I have no relevant financial relationships

3. Aortic Valve Calcification
Detected in 28% to 55% ESRD patients.
Has an average age of onset that is 10 to 20 years earlier than in patients with normal renal function
ESRD patients with AS: Annual decrease in AVA of 0.23 cm2 compared with 0.05 cm2 to 0.1 cm2 among non-uremic patients

4. Prevalence of CKD in TAVR Patients PARTNER trial and Random Access
Thourani, V.H., et al., Impact of Preoperative Chronic Kidney Disease in 2,531 High-Risk and Inoperable Patients Undergoing Transcatheter Aortic Valve Replacement in the PARTNER Trial. Ann Thorac Surg, (4): p

5. Baseline CKD Impacts Mortality Post TAVR
Thourani, V.H., et al., Impact of Preoperative Chronic Kidney Disease in 2,531 High-Risk and Inoperable Patients Undergoing Transcatheter Aortic Valve Replacement in the PARTNER Trial. Ann Thorac Surg, (4): p

6. CKD Is An Independent Predictors of 1-Year Mortality Post TAVR
Thourani, V.H., et al., Impact of Preoperative Chronic Kidney Disease in 2,531 High-Risk and Inoperable Patients Undergoing Transcatheter Aortic Valve Replacement in the PARTNER Trial. Ann Thorac Surg, (4): p

7. TAVR Can Improve Renal Function By Hospital Discharge%
Blair, J.E., et al., Inhospital and Post-discharge Changes in Renal Function After Transcatheter Aortic Valve Replacement. Am J Cardiol, (4): p

8. Renal Failure; Most Common TAVR Complication
1 year post TF TAVR
Walters, D.L., et al., Initial experience with the balloon expandable Edwards-SAPIEN Transcatheter Heart Valve in Australia and New Zealand: the SOURCE ANZ registry: outcomes at 30 days and one year. Int J Cardiol, (3): p

9. Post TAVR Acute Kidney Injury And 1-Year Mortality In 218 Patients Undergoing TAVR
1-year cumulative rate of death over time
Thirty day landmark analysis
Genereux, P., et al., Incidence and effect of acute kidney injury after transcatheter aortic valve replacement using the new valve academic research consortium criteria. Am J Cardiol, (1): p

10. Post TAVR AKI Predicts Poor Outcomes
Even after accounting for STS scores, AKI remained predictive of adverse events
Thongprayoon, C., et al., Incidence and risk factors of acute kidney injury following transcatheter aortic valve replacement. Nephrology (Carlton), (12): p

11. Mechanisms of Renal Injury During TAVR
Operative renal hypo-perfusion
Balloon valvuloplasty and valve deployment
Rapid ventricular pacing
Atheromatous embolization
Delivery system manipulation in aorta
Valvuloplasty and valve deployment
Contrast agents

12. Contrast Media Volume During TAVR and Acute Kidney Injury* # ! #
Increase in Crt.>0.5 mg/dl or 25% from baseline >48 hours post TAVR
* Decrease in eGFR>25% or increase in Crt.>50% from baseline >7 days post TAVR
Increase in Crt.>0.3 mg/dl or 50% from baseline >72 hours post TAVR !
Thongprayoon, C., et al., The effects of contrast media volume on acute kidney injury after transcatheter aortic valve replacement: a systematic review and meta-analysis. J Evid Based Med, 2016

13. Predictors of Post TAVR Acute Kidney Injury VARC-2 Criteria For Acute Kidney Injury
Arsalan et.al. Am J Cardiol 2016;117:1327e1331. Prognostic Usefulness of Acute Kidney Injury After Transcatheter Aortic Valve Replacement

14. Trans-Apical TAVR and Acute Kidney Injury
Thongprayoon, C., et al., The risk of acute kidney injury following transapical versus transfemoral transcatheter aortic valve replacement: a systematic review and meta-analysis. Clin Kidney J, (4): p

15. Renal Protection Strategies During TAVR
Identify high risk groups: Baseline eGFR <30
Modifiable factors
Saline hydration (Poseidon, RenalGuard)
Minimize intra-procedural hypotension
Minimalist contrast strategy (including pre TAVR work up)

16. PROTECT-TAVI- RenalGuard Furosemide-Induced Diuresis With Matched Isotonic Intravenous Hydration
Barbanti, M., et al., Acute Kidney Injury With the RenalGuard System in Patients Undergoing Transcatheter Aortic Valve Replacement: The PROTECT-TAVI Trial (PROphylactic effecT of furosEmide-induCed diuresis with matched isotonic intravenous hydraTion in Transcatheter Aortic Valve Implantation). JACC Cardiovasc Interv, (12): p

17. Renal Protection Strategies During TAVR
Identify high risk groups: Baseline eGFR <30
Modifiable factors
Saline hydration (Poseidon, RenalGuard)
Minimize intra-procedural hypotension
Minimalist contrast strategy (including pre TAVR work up)

18. Determination of Co-Planar Gantry Angle Without Contrast
Align 3 pigtails base in 3 cusps
Confirm pigtail contact with cusps

19. Conclusion CKD is very common in TAVR patients
Stage 3 CKD patients have increased risk of AKI/mortality
TAVR can improve renal function
Renal protection strategies should be implemented in those patients

20. Thank you