Impact of Preprocedural B-Type Natriuretic Peptide Levels on the Outcomes After Transcatheter Aortic Valve Implantation

doi:10.1016/j.amjcard.2015.09.031

The American Journal of Cardiology

Volume 116, Issue 12, 15 December 2015, Pages 1904-1909

https://doi.org/10.1016/j.amjcard.2015.09.031 Get rights and content

There are limited data on the effect of baseline B-type natriuretic peptide (BNP) on the outcome after transcatheter aortic valve implantation (TAVI). We investigated the influence of baseline BNP levels on the short-term and midterm clinical outcomes after TAVI. During a 3-year period, 780 patients with severe aortic stenosis underwent TAVI at our institute and had baseline BNP levels. We compared the high, mid, and low tertiles of BNP levels. TAVI end points, device success, and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. Device success was significantly lower for patients with high BNP (98.1% vs 96.2% vs 91.9% for the low, mid, and high BNP tertiles, respectively; p = 0.003). All-cause mortality up to 30 days was 1.2% (3 of 260) versus 2.3% (6 of 260) versus 5% (13 of 260), respectively (p = 0.03). Six-month mortality rate was 4.1% (10 of 241) for the low BNP tertile, 5% (12 of 239) for the mid BNP tertile, and 17.1% (40 of 234) for the high BNP tertile (p <0.001). In the multivariate model, high tertile of baseline BNP was found to be significantly associated with all-cause mortality (hazard ratio 3.3, 95% confidence interval 1.64 to 6.48; p = 0.001). In conclusion, elevated BNP levels are associated with increased short-term and midterm mortality after TAVI. We recommend measurement of baseline BNP as part of risk stratification models for TAVI.

Section snippets

Methods

We examined consecutive patients with severe symptomatic AS who underwent TAVI during a 3-year period at our institute. All patients had congestive heart failure with New-York Heart Association class II to IV symptoms. All underwent preprocedural coronary angiography to assess the need of revascularization. Aortic valve disease was assessed initially with transthoracic echocardiography followed by an electrocardiography-gated, multislice computed tomography angiography study. Sizing for TAVI

Results

From January 2012 to January 2015, 803 patients underwent TAVI at our institute. In this cohort, 780 patients (97.1%) had baseline BNP level. The low BNP tertile had a mean BNP of 103 ± 46 pg/ml; the mid BNP tertile had 297 ± 75 pg/ml; and the high BNP tertile had 1,327 ± 1,072 pg/ml. Transfemoral approach was used in 86.2% of the cases, transapical approach in 5%, transaortic approach in 7.8%, and subclavian approach in 0.9%. The baseline clinical patient characteristics and pre-TAVI imaging

Discussion

The results of the present study indicate that high level of BNP before TAVI negatively influence the short-term and midterm clinical outcomes of the procedure. Patients in the high tertile BNP group had lower device success, longer hospitalization period, higher rates of periprocedural cardiogenic shock, and higher 30-day mortality rate than patients with lower BNP levels. In a multivariate model, high BNP was still a strong predictor of overall mortality during the study follow-up period.

BNPs

Disclosures

Dr. Makkar has received grant support from Edwards Lifesciences Corporation and St. Jude Medical; is a consultant for Abbott Vascular, Cordis, and Medtronic; and holds equity in Entourage Medical. Dr. Jilaihawi is a consultant for Edwards Lifesciences Corporation, St. Jude Medical, and Venus MedTech. All other authors report no relationships that could be construed as a conflict of interest.

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Cited by (23)

Multimarker Approach to Identify Patients With Higher Mortality and Rehospitalization Rate After Surgical Aortic Valve Replacement for Aortic Stenosis
2018, JACC: Cardiovascular Interventions
Citation Excerpt :
Among asymptomatic patients with moderate or severe AS, a higher natriuretic peptide level predicts symptom onset or a clinical composite that is usually dominated by the performance of AVR (17). Some studies show that a higher natriuretic peptide level is associated with increased mortality among symptomatic patients treated with valve replacement (18). Additional studies have evaluated high-sensitivity troponin, GDF15, and soluble ST2, among others (5,6,19).
This study sought to evaluate whether a multimarker approach might identify patients with higher mortality and hospitalization rates after aortic valve replacement (AVR) for aortic stenosis (AS).
The society valve guidelines include accepted triggers for AVR in patients with severe asymptomatic AS, but circulating biomarkers do not have a clear role.
From a prospective registry of patients undergoing cardiac surgery between 2000 and 2012, 665 treated with surgical AVR (441 isolated) were evaluated. Seven biomarkers were measured on blood samples obtained before AVR. Biomarker levels were adjusted to account for the influence of age, sex, body mass index, and renal function; the median was used to determine an elevated value. Endpoints included all-cause mortality and all-cause and cardiovascular hospitalizations. Mean follow-up was 10.7 years and 299 (45%) died.
Patients with 0 to 1, 2 to 3, 4 to 6, and 7 biomarkers elevated had 5-year mortality of 10%, 12%, 24%, and 33%, respectively, and 10-year mortality of 24%, 35%, 58%, and 71%, respectively (log-rank p < 0.001). The association between an increasing number of elevated biomarkers and increased all-cause mortality was observed among those with minimal symptoms (New York Heart Association functional class I or II) and those with a low N-terminal pro–B-type natriuretic peptide (p < 0.01 for both). Compared with those with 0 to 1 biomarkers elevated, patients with 4 to 6 or 7 biomarkers elevated had an increased hazard of mortality after adjustment for clinical risk scores (p < 0.01) and a 2- to 3-fold higher rate of all-cause and cardiovascular rehospitalization after AVR. Similar findings were obtained when evaluating cardiovascular mortality. Among patients with no or minimal symptoms, 42% had ≥4 biomarkers elevated.
Among patients with severe AS treated with surgical AVR, an increasing number of elevated biomarkers of cardiovascular stress was associated with higher all-cause and cardiovascular mortality and a higher rate of repeat hospitalization. A multimarker approach may be useful in the surveillance of asymptomatic patients with severe AS to optimize surgical timing.
How to predict futility: The holy grail of transcatheter aortic valve implantation
2018, Revista Portuguesa de Cardiologia
Post-procedural N-terminal pro-brain natriuretic peptide predicts one-year mortality after transcatheter aortic valve implantation
2018, Revista Portuguesa de Cardiologia
Citation Excerpt :
There is a correlation between NT-proBNP levels and severity of aortic stenosis.4 The post-procedural impact of NT-proBNP has been studied,6–9 and found to predict one-year mortality.10 However there is no established threshold beyond which outcomes worsen.
Natriuretic peptides are ubiquitously used for diagnosis, follow-up and prognostic assessment in various heart conditions. N-terminal pro-brain natriuretic peptide (NT-proBNP) correlates with aortic stenosis severity, however its significance after transcatheter aortic valve implantation (TAVI) is not well established.
We aimed to assess the prognostic value of NT-proBNP at one year in patients undergoing TAVI.
This single-center retrospective analysis included 151 patients in whom both baseline and one-month post-procedure NT-proBNP were measured, from 206 consecutive patients undergoing TAVI between November 2008 and December 2014. The best cut-off values of both baseline and one-month post-TAVI NT-proBNP for one-year mortality were determined by receiver operating characteristic curve analysis. Independent predictors of one-year mortality were assessed by Cox regression.
The areas under the curve of baseline and post-procedural NT-proBNP for one-year mortality were 0.60 and 0.72, with the best cut-off values of 1350 and 2500 pg/ml, respectively. Atrial fibrillation, procedure-related major bleeding, baseline NT-proBNP higher than 1350 pg/ml, post-procedural NT-proBNP higher than 2500 pg/ml, higher creatinine and Society of Thoracic Surgeons score, and lower left ventricular ejection fraction were associated with one-year mortality. Only post-procedural NT-proBNP was independently and negatively associated with one-year survival (HR 5.9, 95% CI 1.6-21.7, p=0.008).
Baseline NT-proBNP did not predict one-year mortality; on the other hand one-month post-procedural NT-proBNP higher than 2500 pg/ml may identify a high-risk subset of patients, allowing better management, care and hypothetically outcome.
Os peptídeos natriuréticos são usados de forma ubíqua para o diagnóstico, seguimento e avaliação prognóstica em cardiologia. O NT-ProBNP correlaciona-se com a gravidade da estenose aórtica, porém o seu significado após VAP não está bem estabelecido.
Avaliar o valor prognóstico do NT-ProBNP nos doentes submetidos a VAP.
Análise retrospetiva de 151 doentes, de um registo de 206 doentes consecutivos de novembro de 2008 a dezembro de 2014, com doseamentos de NT-ProBNP basal e após um mês da implantação de VAP. Os preditores independentes de mortalidade a um ano foram avaliados por regressão Cox.
Os melhores valores discriminativos de NT-ProBNP basal e pós-procedimento foram 1.350 e 2.500, respetivamente. Somente um valor de NT-ProBNP pós-procedimento superior a 2.500pg/ml foi preditor independente e negativamente associado à sobrevida a um ano (HR 5,9; 95% IC 1,6-21,7; p = 0,008).
O NT-ProBNP basal não previu a mortalidade a um ano. Por outro lado, o NT-ProBNP superior a 2.500pg/ml após o procedimento identificou um subgrupo de doentes de alto risco, permitiu um melhor manejo, seguimento e possíveis resultados.
Inevitability or opportunity?
2017, Journal of Thoracic and Cardiovascular Surgery
Non-cardiac aspects of aortic stenosis in the elderly: A review
2017, Revista Espanola de Geriatria y Gerontologia
La estenosis aórtica (EA) es la valvulopatía más frecuente en el anciano. El tratamiento es el reemplazo valvular bien por cirugía abierta o en los casos de pacientes de alto riesgo quirúrgico o inoperables mediante transcatheter aortic valve implantation (TAVI). Sin embargo, alrededor del 40% de los ancianos tratados con TAVI presentan malos resultados por falta de mejoría clínica o muerte. Esta revisión analiza los aspectos no cardiológicos de los pacientes con EA que pueden ayudar a responder a 3 preguntas clave: 1) ¿la sintomatología que presenta el paciente se debe exclusivamente a la EA o existen otros factores o comorbilidades que puedan justificarla o acrecentarla?; 2) ¿qué posibilidades de mejoría del estado de salud y calidad de vida tiene el paciente si se hace el reemplazo valvular?, y 3) ¿en qué medida podemos disminuir el riesgo de que el reemplazo sea fútil?
Aortic stenosis (AS) is the most frequent valve disease in the elderly population Treatment is valve replacement either by open surgery, or in the case of patients at high surgical risk, by TAVI (Transcatheter Aortic Valve Implantation). However, almost 40% of patients who have undergone TAVI show poor health outcomes, either due to death or because their clinical status does not improved. This review examines the non-cardiac aspects of patients with AS, which may help answer three key questions in order to evaluate this condition pre-surgically: 1) Are the symptoms presented by the patient exclusively explained by the AS, or are there other factors or comorbidities that could justify or increase them?, 2) What possibilities for improvement of health status and quality of life has the patient after the valve replacement?, and 3) How can we reduce the risk of a futile valve replacement?
Plasma N-terminal pro-B-type natriuretic peptide in the detection of aortic valve stenosis
2023, Scandinavian Journal of Clinical and Laboratory Investigation

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: Funding: The study was funded by the Department Internal Resources.

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Valvular Heart DiseaseImpact of Preprocedural B-Type Natriuretic Peptide Levels on the Outcomes After Transcatheter Aortic Valve Implantation

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Int J Cardiol

Am J Cardiol

Valvular Heart Disease
Impact of Preprocedural B-Type Natriuretic Peptide Levels on the Outcomes After Transcatheter Aortic Valve Implantation