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Arif Asif, MD, FASN, FNKF

Professor of Medicine

Director, Interventional Nephrology

Division of Nephrology and Hypertension

University of Miami Miller School of Medicine,

Miami, FL

Gerald A. Beathard State of the Art Lecture

No Conflict of Interest

Tricuspid Regurgitation

InfectionVenous Stenosis

Tricuspid Regurgitation

InfectionVenous Stenosis

• Lead adherence

• Lead induced valve perforation

• Lead induced impingement

• Lead entanglement.

Lin et al. J Am CollCardiol 45:1672-1675, 2005

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Becker et al. Circulation 1972;46;409-412

Vecht et al. British Heart Journal, 1976, 38, 1359-1362

Asif et al. Seminars in Dialysis, 2010

Nath et al. J Am Coll Cardiol 43:405-409, 2004

• n=154 (severe TR NYHA III-IV + cardiac device).

• 40/154 had direct evidence of TR due to the lead.

• Severe Tricuspid regurgitation can occur in 26.2% of patients with cardiac rhythm devices.

Lin et al. J Am CollCardiol 45:1672-1675, 2005

Mean arterial pressure90 mmHg

1500-3000cc/min

Tricuspid Regurgitation

InfectionVenous Stenosis

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• Rate of lead infection in the general population ranges from 0.8% to 5.7%.

•Bisno, AL et al, American Society for Microbiology Press, Washington, DC 2000. p. 247 •UpToDate 2009

• Patients with chronic kidney disease are at an increased risk of infection.

• Infection is the second leading cause of death in end stage renal disease patients.

• Annual percentage of mortality secondary to sepsis can be 100 to 300 fold higher in dialysis patients compared to general population.

Fontenaille C et al. Nephron. 1993;64:95-100Conlon PJ et al. Am J Kidney Dis. 1997;30:521-524Jaber BL et al. Kidney Int. 2000;58:1758-1764Langberg J et al. PACE. 2006;29:142-145

Fontenaille C et al. Nephron. 1993;64:95-100Conlon PJ et al. Am J Kidney Dis. 1997;30:521-524Jaber BL et al. Kidney Int. 2000;58:1758-1764Langberg J et al. PACE. 2006;29:142-145

US Renal Data System, USRDS 2008 annual data reportSarnak MJ, Jaber BL. Kidney Int. 2000 Oct;58(4):1758-64

Multivariate predictors of device infection. CHF= congestive heart failure. High creatinine is defined as Cr ≥1.5 mg/dL and low GFR as CrCl ≤60 mL/min/1.73 m2.

Bloom H et al. Pacing ClinElectrophysiol. 2006

Lekkerker et al. Heart 2009

Tompkins et al: J Cardiovasc Electrophsiol April 2011.

0

10

20

30

40

50

STAGE I STAGE II STAGE IIIA STAGE IIIB STAGE IV STAGE V ADVANCED

RENAL DISEASE

(IIIB + IV + V)

patient %

eGFR

106±11.4

eGFR

73±8.3

eGFR

51.8±4.3

eGFR

37.5±4.3 eGFR

21.9±3.8

eGFR

10±1.9

eGFR

22.6±3.3

Unpublished data: University of Miami Miller School of Medicine

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Asif et al: Seminars in Dialysis 2012

Carrillo RG, Garisto JD, Salman L, Asif A. Clinical Nephrology, July 2010

Courtesy: Brinda Desiraju, MD

Carrillo RG, Salman,… Asif A. American Journal of Kidney Disease 2010

� Retrospective study of 50 patients.

� Catheters with an indwelling CRD were found in 14 patients

Desiraju and Mittman:Cardiac rhythm devices in hemodialyzed patients: experience in a single urban vascular access center. ASN (2011)

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Tricuspid Regurgitation

InfectionVenous Stenosis

70% patients became symptomatic with CIEDTeruya et al: Ann Vasc Surg 17:526–529, 2003

Desiraju et al: ASN 2011

• Access ligation

• Moving the access or the device to the contra-lateral side.

• Stent placement

• Percutaneous balloon angioplasty

Chuang et al: Am J Nephrol 21:406–440, 2001

Moving the device or the access to the contra-lateral side

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From Beathard From Asif

From DesirajuFrom Desiraju

Approximately 20% of the patients have stenosis located in the

SUPERIOR VENA CAVA

Desiraju and Mittman: J Am Soc Nephrol 2011Asif et al: Semin Dial 22:671-676, 2009

Saad et al. J Vasc Access 2010Konner: Nephrol Dial Transplant 1997Bolad et al. Catheterization and Cardiovascular Interventions 2005Slonim et al. J Vasc Interv Radiol 2000

Saad TF, Myers R, Cicone J:

J Vasc Access 11:293-302, 2010

Saad TF, Myers R, Cicone J:

J Vasc Access 11:293-302, 2010

Wilkoff& Carrillo et al: Heart Rhythm 6:1085-1104, 2009

� INFECTION

� Stent graft=6%

Haskal et al: NEJM 2010

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Asif et al. Semin Dial 22:671-676, 2009

18%

9%

Average of 2.1 procedures / year

95%

86%

73%

Asif et al. Semin Dial 22:671-676, 2009

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ASDIN 6th Annual Scientific meeting 2010

Central venous stenosis

Infections

Tricuspid valve regurgitation

Salman and Asif: Kidney International 2011

• 1, 2 and 5 year survival of 96%, 90% and 74%

• Equivalent functional performance

• CHF readmissions (Endo=31.5%, Epi=26.2%; p=0.53)

• Improvement in NYHA functional class (Endo=49.6%, Epi=59%; p=0.17)

• All-cause mortality at a follow-up of 39±14 months (Epi=30.6%, Endo=23.8%)

Dodge-Khatami et al: J Card Surg 2000Walker et al: J Am Coll Card 2004Cohen et al: Circulation 2001Ailawadi et al: Heart Rhythm 2010

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Asif et al. Semin Dial 2012

Asif et al. Semin Dial 2012

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An FFBI position statement supporting cardiac rhythm devices to be placed by the epicardial approach as a first option for patients with both kidney failure and

cardiovascular disease.

� Roger Carrillo, MD, CT surgery

� Gustavo Lopera, MD, EP

� UrwaBarakat, M.D. Interventional Cardiology

� Rick Preston, M.D. Pharmacology

� Tony Salum, M.D. Infectious Diseases

� Students, residents and fellows in training.

� Loay Salman, M.D. Interventional Nephrology

� Donna Merrill, R.N. Interventional Nephrology