Heart valve prosthesis selection in patients with end-stage renal disease requiring dialysis: a systematic review and meta-analysis

Context There is little evidence guiding heart valve prosthesis selection in patients with end-stage renal disease (ESRD) on dialysis. Objectives To perform: 1) a systematic review of studies examining valve replacement in patients with ESRD on dialysis; and 2) a quantitative meta-analysis comparing survival and valve-related outcomes following valve replacement with bioprostheses versus mechanical prostheses in this population. Data sources English studies published from 1990 onwards. Study selection Studies were included in the meta-analysis if they compared bioprostheses with mechanical prostheses in patients with ESRD on dialysis. Data extraction Extracted summary estimates included the hazard ratio (HR) for death, and the odds ratio (OR) for developing valve-related complications due to the use of bioprostheses versus mechanical prosthesis. Results Twelve studies published from 1997 to 2010 were included in this review, of which 9 were used in the meta-analysis. No evidence of publication bias was detected. The aortic valve was the most common valve replaced in these studies (4339/6350), although 11 of the 12 studies also included mitral or multiple valve replacements. No difference in survival was observed between valve types (bioprostheses versus mechanical prostheses hazard ratio 1.3, 95% confidence interval (CI) 1.0-1.9, p=0.09). However, valve replacement with bioprostheses was associated with fewer valve-related complications compared to mechanical prostheses (odds ratio 0.4, 95% CI 0.2-0.7, p=0.002). Conclusions A meta-analysis of the published literature demonstrates no survival difference following valve replacement with either bioprostheses or mechanical prosthesis in patients with ESRD on dialysis. Bioprosthetic valve replacement was associated with fewer valve-related complications. Although this meta-analysis cannot discriminate between the sites of valve implant, these data can likely be extended to include at least aortic valve replacement.