Valve replacement in patients with chronic renal failure requiring hemodialysis: What is the best option: mechanical valve or xenograft?

Heart valve surgery is associated with a significantly increased risk in patients on chronic hemodialysis. Current literature search indicates that there are not enough data available to allow for an evidence-based selection of prothesis for the individual patient. Mechanical prosthesis require oral anticoagulation, which is regarded as an distinctive disadvantage for patients on chronic hemodialysis. Xenografts may carry an increased risk for structural valve deterioration in the presence of chronic renal failure. Therefore the current guidelines of the ACC recommend (class II recommendation) the use of a mechanical valve prothesis in patients with renal failure, on hemodialysis or with hypercalcemia. However, based on our own results as well as on recent publications mid term survival is extremely poor in this patient population. Furthermore accelerated xenograft structural valve deterioration has not been observed as compared to the general population receiving heart valve replacement therapy. Therefore xenografts may be an excellent alternative in patients on chronic dialysis requiring heart valve replacement if valve repair is not feasible. The paradigm of mechanical protheses in this patient group definitely should be reconsidered; however, more data are necessary for an evidence-based decision.