Transfemoral Compared to Transapical Transcatheter Aortic Valve Implantation in Chronic Dialysis-Dependent Patients

<b>Introduction:</b> Patients with end-stage kidney disease (ESRD) represent a high-risk population in terms of both development of and death by cardiovascular diseases. Outcome data of ESRD patients with severe aortic valve stenosis (AS) treated by transcatheter aortic valve implantation (AVI) are scarce. We aim to compare the outcome of ESRD patients undergoing transfemoral (TF) or transapical (TA) AVI. <b>Methods:</b> From June 2006 to December 2019, 176 consecutive patients with ESRD receiving chronic hemodialysis underwent TF- or TA-AVI at two German heart centers. The primary outcome measure was 1-year all-cause mortality. Other outcomes included VARC-3 defined device success and early safety. <b>Results:</b> The cohort comprised 61 (34.7%) patients receiving TA-AVI and 115 (65.3%) patients receiving TF-AVI. Perioperative risk, assessed using the EuroScore II, was not different between groups. VARC-3 defined device success (52.5% vs. 80.0%, <i>p</i> < 0.001) and early safety (27.9% vs. 45.2%, <i>p</i> = 0.025) were lower in TA-AVI patients compared to the TF-AVI group. The 30-day mortality was 4.7-fold higher in TA- compared TF-AVI patients (24.6% vs. 5.2%, <i>p</i> < 0.001). The 1-year mortality was higher in TA- compared with TF-AVI patients (57.3% vs. 27.8%, <i>p</i> < 0.001). By applying a Cox regression analysis, it was found that TA-AVI was the only independent factor associated with 1-year all-cause mortality (HR_adj 2.65 (95%-CI 1.63-4.30), <i>p</i> < 0.001). <b>Conclusions:</b> In ESRD patients, TA-AVI was associated with worse early outcomes and increased mortality up to 1 year compared to the TF-AVI. Transfemoral access is recommended, when feasible, in ESRD patients undergoing TAVI.