P4666Higher BNP levels after transcatheter aortic valve implantation are associated with increased mortality and hospitalizations

Background

Among patients with aortic stenosis (AS), the adverse association between increased B-type natriuretic peptide (BNP) levels and worse clinical outcomes, including mortality and hospitalization after valve replacement, has been demonstrated. However, little attention has been paid to the clinical consequences of BNP levels after valve replacement, which may have implications for medical therapy prescribed after the procedure.

Purpose

Evaluate the association between BNP levels after transcatheter aortic valve implantation (TAVI) and subsequent mortality and hospitalizations.

Methods

Among intermediate, high, and extreme risk patients with severe symptomatic AS who received TAVI for native valve AS in the PARTNER II and S3 clinical trials or registries, we included 3260 patients who had BNP measured at baseline. Patients from sites which measured NTproBNP were excluded. To account for factors that influence BNP levels, we developed a regression equation–including age, sex, BMI, creatinine, study site, and the upper limit of normal of the BNP assay used for a given measurement–to determine expected BNP. BNP ratio was determined pre-TAVR and at discharge, 30 days, and 1 year and calculated as the actual BNP/expected BNP. Using a landmark approach, the relationships between (1) BNP ratio at 30 days or (2) delta BNP ratio between discharge and 30 days and subsequent outcomes between 30 days and 1 year were assessed. The primary outcome was a composite of cardiovascular (CV) mortality or hospitalization. Adjustment was made for 20 baseline and post-procedural factors known to influence outcomes.

Results

Higher BNP ratio at 30 days was associated with higher CV mortality or hospitalization between 30 days and 1 year (adjusted hazard ratio [aHR] 1.07 per increase of 1 in the BNP ratio, 95% CI 1.04–1.10, p<0.001), whereas baseline BNP ratio was not (p=0.38). A similar relationship was shown for the components of this composite: CV mortality (aHR 1.08, 95% CI 1.04–1.12, p<0.001) and hospitalizations (aHR 1.04, 95% CI 1.01–1.08, p=0.01). Adjusted for discharge BNP ratio and other factors, a greater decrease in BNP ratio between discharge and 30 days was also associated with lower CV mortality or hospitalization between 30 days and 1 year (aHR 0.95 per decrease of 1 in the BNP ratio, 95% CI 0.92–0.99, p=0.006). Similar relationships were observed for all-cause mortality and when examining the relationship between 1 year BNP ratio and outcomes between 1 and 2 years.

Conclusion

Higher BNP ratio after TAVI is associated with higher subsequent all-cause and CV mortality and hospitalizations, whereas baseline BNP ratio was not. Greater decrease in BNP ratio between discharge and 30 days is associated with better outcomes. Further investigation is warranted to understand these findings and determine whether intensification of medical therapy to decrease BNP after TAVR may improve patient outcomes.

Acknowledgement/Funding

The PARTNER 2 Trial was funded by Edwards Lifesciences

Integrating Quality of Life and Survival Outcomes in Cardiovascular Clinical Trials

Background Survival and health status (eg, symptoms and quality of life) are key outcomes in clinical trials of heart failure treatment. However, health status can only be recorded on survivors, potentially biasing treatment effect estimates when there is differential survival across treatment groups. Joint modeling of survival and health status can address this bias. Methods and Results We analyzed patient-level data from the PARTNER 1B trial (Placement of Aortic Transcatheter Valves) of transcatheter aortic valve replacement versus standard care. Health status was quantified with the Kansas City Cardiomyopathy Questionnaire (KCCQ) at randomization, 1, 6, and 12 months. We compared hazard ratios for survival and mean differences in KCCQ scores at 12 months using several models: the original growth curve model for KCCQ scores (ignoring death), separate Bayesian models for survival and KCCQ scores, and a Bayesian joint longitudinal-survival model fit to either 12 or 30 months of survival follow-up. The benefit of transcatheter aortic valve replacement on 12-month KCCQ scores was greatest in the joint-model fit to all survival data (mean difference, 33.7 points; 95% credible intervals [CrI], 24.2-42.4), followed by the joint-model fit to 12 months of survival follow-up (32.3 points; 95% CrI, 22.5-41.5), a Bayesian model without integrating death (30.4 points; 95% CrI, 21.4-39.3), and the original growth curve model (26.0 points; 95% CI, 18.7-33.3). At 12 months, the survival benefit of transcatheter aortic valve replacement was also greater in the joint model (hazard ratio, 0.50; 95% CrI, 0.32-0.73) than in the nonjoint Bayesian model (0.54; 95% CrI, 0.37-0.75) or the original Kaplan-Meier estimate (0.55; 95% CI, 0.40-0.74). Conclusions In patients with severe symptomatic aortic stenosis and prohibitive surgical risk, the estimated benefits of transcatheter aortic valve replacement on survival and health status compared with standard care were greater in joint Bayesian models than other approaches.

Association of Paravalvular Regurgitation With 1-Year Outcomes After Transcatheter Aortic Valve Replacement With the SAPIEN 3 Valve

Importance

Moderate/severe and even mild paravalvular regurgitation (PVR) are associated with increased mortality following transcatheter aortic valve replacement (TAVR) with first and second generations of transcatheter valves.

Objective

To examine the incidence, evolution, and effect on 1-year outcomes of PVR following TAVR with a third-generation balloon-expandable transcatheter heart valve.

Design, Setting, and Participants

Prespecified analysis of PVR in the Placement of Aortic Transcatheter Valves (PARTNER) II SAPIEN 3 trial, conducted between October 1, 2013, and September 3, 2014. Multicenter, nonrandomized registry of 1661 patients at intermediate or high surgical risk undergoing TAVR with the SAPIEN 3. Patients with severe, symptomatic aortic stenosis and high/intermediate surgical risk were enrolled in the registry at 51 sites in the United States and Canada.

Interventions

Transcatheter aortic valve replacement with the SAPIEN 3 valve.

Main Outcomes and Measures

Paravalvular regurgitation was assessed in a core laboratory at 30 days and 1 year according to a 5-class scheme: 0, none or trace; 1, mild; 2, mild to moderate; 3, moderate; 4, moderate to severe; and 5, severe. We assessed the effect of PVR on 1-year mortality and heart failure rehospitalization.

Results

Among the 1661 included in the registry, 1592 received a SAPIEN 3 valve and had assessment of PVR. Of these patients, 55.7% had none-trace PVR, 32.6% had mild, 8.2% had mild to moderate, and 3.5% had at least moderate PVR at 30 days. At 1 year, 9.3% of patients had died and 14.2% had been rehospitalized. Only patients with at least moderate PVR had higher 1-year mortality (hazard ratio [HR], 2.40; 95% CI, 1.30-4.43; P = .005) and composite of mortality/rehospitalization (HR, 2.35; 95% CI, 1.52-3.62; P < .001). In a paired comparison including 1213 patients, 73% of the patients with at least moderate PVR at 30 days showed a reduction in PVR severity of at least 1 PVR class at 1 year.

Conclusions and Relevance

In this series of patients undergoing TAVR with the SAPIEN 3 valve, at least moderate PVR was rare but associated with increased risk of death and heart failure rehospitalization at 1 year. Even the upper range of the mild class in the 3-class grading scheme (ie, mild to moderate in the 5-class scheme) had no significant effect on short-term mortality or rehospitalization. Most patients with at least moderate PVR at 30 days showed a decrease of PVR severity grade at 1 year.

Trial Registration

clinicaltrials.gov Identifier: NCT01314313.

Association of Transcatheter Aortic Valve Replacement With 30-Day Renal Function and 1-Year Outcomes Among Patients Presenting With Compromised Baseline Renal Function: Experience From the PARTNER 1 Trial and Registry

Importance

The frequency of baseline renal impairment among high-risk and inoperable patients with severe aortic stenosis undergoing a transcatheter aortic valve replacement (TAVR) and the effect of TAVR on subsequent renal function are, to our knowledge, unknown.

Objective

To determine the effect of TAVR among patients with baseline renal impairment.

Design, Setting, and Participants

This substudy of patients with baseline renal impairment (estimated glomerular filtration rate [eGFR] ≤ 60 mL/min) and paired baseline and 30-day measures of renal function undergoing TAVR in the PARTNER 1 trial and continued access registries was conducted in 25 centers in the United States and Canada.

Main Outcomes and Measures

Patients were categorized with improved eGFR (30-day follow-up eGFR≥10% higher than baseline pre-TAVR), worsened eGFR (≥10% lower), or no change in renal function (neither). Baseline characteristics, 30-day to 1-year all-cause mortality, and repeat hospitalization were compared. Multivariable models were constructed to identify predictors of 1-year mortality and of improvement/worsening in eGFR.

Results

Of the 821 participants, 401 (48.8%) were women and the mean (SD) age for participants with improved, unchanged, or worsening eGFR was 84.90 (6.91) years, 84.37 (7.13) years, and 85.39 (6.40) years, respectively. The eGFR was 60 mL/min or lower among 821 patients (72%), of whom 345 (42%) improved, 196 (24%) worsened, and 280 (34%) had no change at 30 days. There were no differences in baseline age, body mass index, diabetes, chronic obstructive pulmonary disease, coronary artery disease, peripheral arterial disease, hypertension, pulmonary hypertension, renal or liver disease, New York Heart Association III/IV symptoms, transaortic gradient, left ventricular ejection fraction, or procedural characteristics. The group with improved eGFR had more women, nonsmokers, and a lower cardiac index. Those with worsening eGFR had a higher median Society of Thoracic Surgeons score and left ventricle mass. From 30 days to 1 year, those with improved eGFR had no difference in mortality or repeat hospitalization. Those with worsening eGFR had increased mortality (25.5% vs 19.1%, P = .07) but no significant increases in repeat hospitalization or dialysis. Predictors of improved eGFR were being female (odds ratio [OR], 1.38; 95% CI, 1.03-1.85; P = .03) and nonsmoking status (OR, 1.49; 95% CI, 1.11-1.01; P = .01); predictors of worsening eGFR were baseline left ventricle mass (OR, 1.00; 95% CI, 1.00-1.01; P = .01), smoking (OR, 1.51; 95% CI, 1.06-2.14; P = .02), and age (OR, 1.03; 95% CI, 1.00-1.05; P = .05); and predictors of 1-year mortality were baseline left ventricular ejection fraction (OR, 0.98; 95% CI, 0.97-0.99; P = .003), baseline eGFR (OR, 0.98; 95% CI, 0.96-0.99; P < .001), and worsening eGFR vs no change in eGFR (OR, 1.51; 95% CI, 1.02-2.24; P = .04).

Conclusions and Relevance

Baseline renal impairment was frequent among patients who underwent TAVR. While improved eGFR did not improve 1-year outcomes, worsening eGFR was associated with increased mortality.

Trial Registration

clinicaltrials.gov Identifier: NCT00530894.