Utility Of Standardized Pre-CTA Hydration Protocol On Patients Referred For Transcatheter Aortic Valve Replacement
Abdelrahim E, Fuller B, Coriasso N, Alalwan Y, Hughes C, Aljamal A, Wang D, Pantelic M, Song T, Eng M, Frisoli T, Villablanca P, Wyman J, O'Neill W, and Lee J. Utility Of Standardized Pre-CTA Hydration Protocol On Patients Referred For Transcatheter Aortic Valve Replacement. Journal of Cardiovascular Computed Tomography 2020; 14(3):S37.
Journal of Cardiovascular Computed Tomography
Introduction: ECG-gate computed tomography angiography (CTA) is the standard technique for pre-procedural planning prior to transcatheter aortic valve replacement (TAVR). CTA requires use of potentially nephrotoxic iodinated contrast, limiting use in patients with renal dysfunction. We evaluated the utility of a tiered hydration protocol in patients with renal dysfunction referred for TAVR.
Methods: 258 patients (52.7% male, age 79 ± 8 years) who underwent TAVR between 1/1/18 and 12/30/18 were retrospectively evaluated. Pre-procedural CTA was performed per institutional protocols with weight based contrast dosing. Patients requiring hemodialysis prior to CTA were excluded. Patients with GFR <22ml/min did not receive CTA. Patients with GFR 22 - 40 ml/min underwent hydration protocol guidelines: Outpatients received normal saline (NS) at ≤3 mL/kg over one hour pre-procedure/test and 1 to 1.5 mL/kg/hour during and up to six hours post-procedure/test. Inpatients received normal saline for 1 mL/kg/hour for 6 to 12 hours pre-procedure/test, intra-procedure, and up to 12 hours post-procedure.
Results: Total baseline creatinine was 1.08 ± 0.41 ng/dL. Hydration protocol patient creatinine levels were 1.67 ± 0.41 ng/dL. Upper quartile of creatinine was 1.91 ng/dL (range 0.79 - 2.65 ng/dL). Average CTA contrast dose was 100 ± 23 mL. 43 (17%) of patients received pre-CTA hydration protocol. Hydration protocol NS total infusion volumes were 490 ± 119 mL (range 40-100ml). Duration between CT and TAVR was 86 ± 155 days. Pre-TAVR creatinine was 1.09 ± 0.39, creatinine at discharge was 1.06 ± 0.73. 3 patients (1%) had ≥1 increase in CKD grade at discharge. No patients required dialysis prior to discharge or within 1 month of TAVR. No complications from hydration protocol were identified.
Conclusions: Utilization of a routine pre-TAVR CT hydration protocol in patients at risk for contrast induced nephropathy is feasible and associated with no new renal dysfunction prior to TAVR, and low rates of new renal dysfunction post TAVR. In TAVR patients hydration carries risks and further study is needed to identify whether a more conservative hydration protocol can be utilized.