title: Valve Selection in End-Stage Renal Disease: Should It Always Be Biological?
abstract: BACKGROUND
  When valve replacement is required in patients with end-stage renal disease (ESRD), it is not clear if mechanical or bioprosthetic valve selection is better. We compared outcomes between ESRD patients who underwent either mechanical or biologic valve replacements at our institution.
  
  
  METHODS
  All patients with ESRD who underwent either mitral or aortic valve replacement from 2002 to 2014 at our institution were reviewed (n = 215; mechanical = 64, biological = 151). A Cox proportional hazards model was used to test the hypothesis that a mechanical valve was correlated with improved long-term survival. Among patients younger than 65 years (n = 123) we also compared survival with the Kaplan-Meier method.
  
  
  RESULTS
  Similar unadjusted survival was found for patients who received either a bioprosthetic or mechanical valve (log-rank p = 0.55). Survival is clearly attenuated in this patient population, with only about half the patients younger than 65 years surviving beyond 2 years. In the proportional hazards model, a mechanical valve was not correlated with improved survival even when controlled for other variables, including shock, endocarditis, mitral valve replacement, and patient age (95% confidence interval for hazard ratio of mechanical valve: 0.64 to 1.62).
  
  
  CONCLUSIONS
  It appears that there is minimal difference in survival after operation for ESRD patients who undergo bioprosthetic or mechanical valve replacement, even in patients younger than 65 years. The attenuated survival of the ESRD population after valve replacement makes the increased burden of anticoagulation (particularly in hemodialysis patients) unattractive. It is likely that only a small portion of ESRD patients benefit from the increased durability of a mechanical valve.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: matthew.williams@uphs.upenn.edu.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Williams
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Nimesh D
authors.initials: ND
authors.lastname: Desai
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: W Clark
authors.initials: WC
authors.lastname: Hargrove
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Pavan
authors.initials: P
authors.lastname: Atluri
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001021:Aortic Valve / Q000601:surgery; D001705:Bioprosthesis; D002114:Calcinosis / Q000209:etiology / Q000517:prevention & control; D000075202:Contraindications; D004696:Endocarditis / Q000453:epidemiology / Q000209:etiology; D006349:Heart Valve Diseases / Q000150:complications / Q000601:surgery*; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000150:complications* / Q000628:therapy; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D011183:Postoperative Complications / Q000188:drug therapy / Q000401:mortality; D016016:Proportional Hazards Models; D016459:Prosthesis-Related Infections / Q000453:epidemiology / Q000209:etiology; D006435:Renal Dialysis; D012189:Retrospective Studies; D019851:Thrombophilia / Q000188:drug therapy / Q000209:etiology
chemical_list: D000925:Anticoagulants