Comparative Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Heart Failure and Chronic Kidney Disease

BACKGROUND: Evidence comparing intermediate-term outcomes of transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) in patients with concomitant heart failure and chronic kidney disease remains limited. METHODS: Using the TriNetX Global Collaborative Network, we conducted a retrospective study of adults with heart failure and chronic kidney disease undergoing TAVI or SAVR between January 2020 and December 2025. We excluded patients with redo procedures, history of endocarditis, prior heart transplant, ventricular assist device placement, or concomitant valve surgery. The primary outcome was all-cause death. Secondary outcomes included acute myocardial infarction, ischemic stroke, acute kidney injury, and all-cause hospitalization. Outcomes were assessed over 2 years of follow-up using Cox proportional hazards models. RESULTS: Before matching, 9575 patients underwent TAVI and 1233 underwent SAVR. Propensity score matching across 21 covariates balanced demographics, comorbidities, medications, and laboratory values, yielding 1034 matched patients in each cohort. During follow-up, TAVI was associated with a higher mortality rate (hazard ratio [HR], 1.56 [95% CI, 1.21-2.01]) and lower risk of acute kidney injury (HR, 0.69 [95% CI, 0.60-0.80]) compared with SAVR. Risks of acute myocardial infarction (HR, 1.12 [95% CI, 0.87-1.44]), ischemic stroke (HR, 1.11 [95% CI, 0.85-1.45]), and all-cause hospitalization (HR, 0.90 [95% CI, 0.81-1.00]) were similar. Sensitivity analyses across alternative modeling strategies yielded directionally consistent results. CONCLUSIONS: In this contemporary-era cohort of patients with heart failure and chronic kidney disease, SAVR was associated with a lower mortality rate, whereas TAVI was associated with less acute kidney injury. These findings suggest important trade-offs between procedural strategies in high-risk cardiorenal populations.