Background - Minimal data exist on the long-term survival of dialysis patients after cardiac valve surgery. Current practice guidelines of the American College of Cardiology/American Heart Association Task Force on the management of patients with valvular heart disease proscribe the use of bioprosthetic (tissue) valves in hemodialysis patients. Methods and Results - Dialysis patients hospitalized for heart valve replacement surgery from 1978 to 1998 were retrospectively identified from the US Renal Data System database. Long-term survival was estimated by the life-table method. The impact of demographic differences and comorbidity on outcome were examined in a Cox proportional hazards model. The in-hospital mortality of 5858 dialysis patients undergoing valve surgery was 20.7%. Aortic valve replacement was performed in 3415 patients (58%), mitral valve replacement in 1848 patients (32%), and combined aortic and mitral valve replacement in 562 patients (10%). Tissue valves were used in 881 patients. There was no significant difference in survival related to type of prosthetic valve. The 2-year survival rate was 39.7±3.5% with tissue valves versus 39.7±1.4% for nontissue valves. Compared with nontissue prosthetic valves, the use of tissue valves was not predictive of death (RR 0.98; 95% CI 0.90 to 1.07). Conclusions - There is no significant difference in survival of dialysis patients after cardiac valve replacement with tissue versus nontissue prosthetic valves. Current practice guidelines proscribing the use of bioprosthetic heart valves in hemodialysis patients should be rescinded.