Long-term prognostic value and serial changes of plasma N-terminal prohormone B-type natriuretic peptide in patients undergoing transcatheter aortic valve implantation

N-terminal pro-B-type natriuretic peptide levels pre-transcatheter aortic valve implantation and relationship with long-term outcomes

Background

Blood levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been suggested as a future guidance tool for the selection of patients for aortic valve replacement. This study aimed to examine how levels of NT-proBNP pre-transcatheter aortic valve implantation (TAVI) is associated with one-year rates of heart failure (HF) admission and mortality following TAVI.

Methods

With Danish nationwide registries, we identified all patients undergoing TAVI from 2014 to 2021 who had at least one recorded NT-pro-BNP measurement within one year before TAVI. Patients were compared by quartiles of pre-TAVI NT-proBNP: quartile 4 (high NT-proBNP group) vs quartile 1-3 (low NT-proBNP group). Comparisons of all-cause mortality and HF-admissions were conducted using Kaplan-Meier analysis, cumulative incidence, and Cox analysis, as appropriate.

Results

We identified 1,140 patients undergoing first-time TAVI with a recorded NT-pro-BNP; 846 (74.2 %) with a low NT-proBNP (<420 pmol/L) (55.0 % male, median age 81 year) and 294 (25.8 %) with a high NT-proBNP (≥420 pmol/L) (53.1 % male, median age 82 year). A high versus low NT-proBNP was associated with increased one-year cumulative incidence of HF-admissions (9.1 % vs. 23.1 %, adjusted HR 2.00 [95 % CI, 1.40-2.85]) and all-cause mortality (6.0 % vs. 14.6 %, adjusted HR 1.95 [95 % CI: 1.24-3.07]). A high NT-proBNP was associated with higher rates of outcomes irrespective of previously known atrial fibrillation, HF, chronic kidney disease, and hypertension.

Conclusion

In patients undergoing TAVI, a baseline NT-proBNP ≥ 420 pmol/L was associated with increased one-year rates of HF-admission and mortality post-TAVI and may be utilized to identify a high-risk population.

N-terminal pro-B-type natriuretic peptide is associated with clinical outcomes after transcatheter aortic valve replacement

BACKGROUND

Limited data on the prognostic value of periprocedural changes of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) after transcatheter aortic valve replacement (TAVR).

METHODS

Data of plasma NT-proBNP were retrospectively collected in 357 patients before TAVR procedure and at discharge from January 1, 2018 to December 31, 2021 in our single center. Patients were grouped as responders and non-responders according to the NT-proBNP ratio (postprocedural NT-proBNP at discharge/ preprocedural NT-proBNP). Responders were defined as NT-proBNP ratio < 1 and non-responders were defined as NT-proBNP ratio ≥ 1. Outcomes were defined according to the Valve Academy Research Consortium (VARC)-3 criteria.

RESULTS

A total of 234 patients (65.5%) and 123 patients (34.5%) were grouped as the responders and the non-responders, respectively. Responders and non-responders were significantly different in both median preprocedural (2103.5 vs. 421.0 pg/ml, p < 0.001) and postprocedural (707.6 vs. 1009.0, p < 0.001) NT-proBNP levels. Patients in the non-responder group were more inclined to have comorbidities of hypertension (73.2% vs. 51.7%, p < 0.001), hyperlipidaemia (46.3% vs. 34.6%, p = 0.031), peripheral vascular disease (20.3% vs. 8.5%, p = 0.001) and pure aortic insufficiency (15.4% vs. 4.3%, p < 0.001). In the contrast, patients in the responder group had higher prevalence of maximum transvalvular velocity (4.6 vs. 4.2 m/s, p < 0.001), reduced left ventricular ejection fraction (58.0% vs. 63.0%, p < 0.001), heart failure (9.4% vs. 2.4%, p = 0.014), mitral regurgitation ≥ moderate (13.7% vs. 4.9%, p = 0.010), tricuspid regurgitation ≥ moderate (12.0% vs. 2.4%, p = 0.002), and pulmonary hypertension (32.9% vs. 13.0%, p < 0.001). Patients in the non-responder group were moderately longer than the responder group in total hospitalization length (14 vs. 12 days, p < 0.001). The non-responder group were significantly associated with cumulative all-cause mortality (p = 0.009) and cardiac mortality (p < 0.001) during the follow-up period.

CONCLUSIONS

Periprocedural changes of NT-proBNP is clinically useful for the risk stratification of survival in patients after TAVR.

B-type natriuretic peptide and N-terminal Pro-B-type natriuretic peptide in severe aortic stenosis: a comprehensive literature review

B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro BNP) are cardiac biomarkers that are released in response to increased ventricular and atrial wall stress. Aortic stenosis (AS) leads to hemodynamic changes and left ventricular hypertrophy and may be associated with natriuretic peptide levels. Several studies have shown that increased natriuretic peptide levels are correlated with AS severity and can predict the need for intervention. It can be useful in risk stratification, monitoring follow-up, and predicting cardiovascular outcomes of patients with severe AS. This paper aims to summarize the evidence of the role of BNP and NT-pro BNP in AS, before and after intervention.

NT-proBNP trajectory after transcatheter aortic valve replacement and its association with 5-year clinical outcomes

Background

There are only limited reports on the trends of NT-proBNP after transcatheter aortic valve replacement (TAVR) in aortic stenosis (AS) and even fewer report on the prognostic value of the NT-proBNP trajectory following TAVR.

Objectives

This study aims to investigate short-term NT-proBNP trajectory following TAVR and explore its association with clinical outcomes in TAVR recipients.

Methods

Aortic stenosis patients undergoing TAVR were included if they had NT-proBNP levels recorded at baseline, prior to discharge, and within 30 days after TAVR. We used latent class trajectory models to identify NT-proBNP trajectories based on their trends over time.

Results

Three distinct NT-proBNP trajectories were identified from 798 TAVR recipients, which were named class 1 (N = 661), class 2 (N = 102), and class 3 (N = 35). Compared to those with trajectory class 1, patients with trajectory class 2 had a more than 2.3-fold risk of 5-year all-cause death and 3.4-fold risk of cardiac death, while patients with trajectory class 3 had a more than 6.6-fold risk of all-cause death and 8.8-fold risk of cardiac death. By contrast, the groups had no differences in 5-year hospitalization rates. In multivariable analyses, the risk of 5-year all-cause mortality was significantly higher in patients with trajectory class 2 (HR 1.90, 95% CI 1.03-3.52, P = 0.04) and class 3 (HR 5.70, 95% CI 2.45-13.23, P < 0.01).

Conclusion

Our findings implied different short-term evolution of NT-proBNP levels in TAVR recipients and its prognostic value for AS patients following TAVR. NT-proBNP trajectory may have further prognostic value, in addition to its baseline level. This may aid clinicians with regards to patient selection and risk prediction in TAVR recipients.

Left atrial volume index predicts future improvement of B-type natriuretic peptide levels after transcatheter aortic valve replacement

In patients with symptomatic severe aortic stenosis (AS), those who experienced readmission due to heart failure after transcatheter aortic valve replacement (TAVR) showed poor prognosis. Furthermore, poor B-type natriuretic peptide (BNP) improvement is associated with increased morbidity and mortality. However, little is known about the clinical parameters related to the change in BNP levels after TAVR procedure. This study population consisted of 127 consecutive patients of symptomatic severe AS with preserved ejection fraction (EF) who underwent transfemoral TAVR (TF-TAVR). Comprehensive transthoracic echocardiography was performed prior to the day of TF-TAVR. BNP was measured serially before and 1 year after TF-TAVR. The median BNP level was significantly decreased from 252.5 pg/ml to 146.8 pg/ml in all 127 patients 1 year after TF-TAVR (P < 0.01). However, the patients could be divided into 2 groups according to decrease (72%) or increase (28%) in plasma BNP level. Multivariate logistic regression analysis revealed that Aortic valve (AV) peak velocity, pre-procedural BNP, and larger left atrial volume index (LAVI) were found to be an independent predictor of increased BNP level 1 year after TAVR (OR 0.55, 95% CI 0.38-0.77; P < 0.01). LAVI were negatively correlated with the change in BNP level before and 1 year after TAVR (r = 0.47, P < 0.01). The ROC analysis demonstrated that 52.9 ml/m2 was the optimal cut-off value of LAVI for decreasing BNP 1 year after TAVR (area under the curve 0.69) with 64% sensitivity and 70% specificity. In addition to AV peak velocity and pre-procedural BNP, LAVI independently predicts future improvement of BNP levels 1 year after TAVR. Our findings indicate an additive predictive value of assessment of LAVI before TAVR procedure for risk stratification.

Heart failure following transcatheter aortic valve replacement

Introduction: Over the past decade, the number of transcatheter aortic valve replacement (TAVR) procedures has increased exponentially. Despite major improvements in both device and successes, the rate of hospital readmission after TAVR remains high, with heart failure (HF) decompensation being one of the most important causes.Areas covered: This review provides an overview of the current status of HF following TAVR, including details about its incidence, clinical impact, contributing factors, and current and future treatment perspectives.Expert opinion: HF decompensation has been identified as the most common cause of rehospitalization following TAVR, and it has been associated with a negative prognosis. Multiple preexisting factors including low flow status, cardiac amyloidosis, myocardial fibrosis, multivalvular disease, pulmonary hypertension, coronary artery disease, and atrial fibrillation have been associated with an increased risk of HF events. Also, multiple post-procedural factors like the occurrence of significant paravalvular leaks, severe prosthesis-patient mismatch, and conduction disturbances have also contributed to increase this risk . Thus, reducing HF events in TAVR recipients would require a multifactorial and multidisciplinary effort including the optimization of the medical treatment and close follow-up and treatment of residual or concomitant valvular disease and conduction disturbance issues. Future studies in this challenging group of patients are warranted.

Long-Term Survival in Patients with or without Implantable Cardioverter Defibrillator after Transcatheter Aortic Valve Implantation

Patients with symptomatic aortic stenosis (AS) can have concomitant systolic heart failure (HF) that persists even after correction of afterload by transcatheter aortic valve implantation (TAVI). These patients qualify as potential candidates for prophylactic therapy with an implantable cardioverter defibrillator (ICD). We compared survival between patients with or without an ICD after successful TAVI. This retrospective study analyzed Kaplan-Meier survival data during a follow-up period of three years in two populations: (a) patients with a left ventricular ejection fraction (LVEF) ≤ 35% before TAVI (overall population); (b) patients with additionally documented LVEF ≤ 35% 3 months after TAVI (persistent LV dysfunction subpopulation). In the overall population, 53 patients with and 193 patients without an ICD had similar baseline characteristics and procedural success rates, and HF medication at discharge was comparable. Three-year mortality rates were 26.4% for patients with an ICD and 24.4% for patients without an ICD (p = 0.758). Cardiovascular death rates were similar between groups (p = 0.914), and deaths were most often attributed to worsening of HF. Survival rates in patients with persistent LV dysfunction with an ICD (n = 24) or without an ICD (n = 59) were similar between groups (p = 0.872), with cardiovascular deaths mostly qualified as worsening HF and none as sudden cardiac death. Patients of the overall study population with biventricular pacing devices showed only a tendency to have better outcomes (p = 0.298). ICD therapy in elderly patients with AS and LV dysfunction undergoing TAVI did not demonstrate a survival benefit during a 3-year follow-up period.

Baseline NT-proBNP Accurately Predicts Symptom Response to Transcatheter Aortic Valve Implantation

Background

Up to 30% of patients undergoing transcatheter aortic valve implantation (TAVI) experience minimal symptomatic benefit or die within 1 year, indicating an urgent need for enhanced patient selection. Previous analyses of baseline NT‐proBNP (N‐terminal pro‐brain natriuretic peptide) and TAVI outcomes have assumed a linear relationship, yielding conflicting results. We reexamined the relationship between baseline NT‐proBNP and symptomatic improvement after TAVI.

Methods and Results

Symptom status, clinical and echocardiographic data, and baseline NT‐proBNP were reviewed from 144 consecutive patients undergoing TAVI for severe symptomatic aortic stenosis. The primary end point was change in New York Heart Association functional class at 1 year. There was a nonlinear, inverted‐U relationship between log‐baseline NT‐proBNP and post‐TAVI change in NYHA class (R²=0.4559). NT‐proBNP thresholds of <800 and >10 000 ng/L accurately predicted no symptomatic improvement at 1 year (sensitivity 88%, specificity 83%, positive predictive value 72%, negative predictive value 93%). In adjusted analyses, baseline NT‐proBNP outside this “sweet‐spot” range was the only factor independently associated with poor functional outcome (high: NT‐proBNP >10 000 ng/L, odds ratio [OR], 65; 95% CI, 6–664; low: NT‐proBNP <800 ng/L, OR, 73; 95% CI, 7–738).

Conclusions

Baseline NT‐proBNP is a useful prognostic marker to predict poor symptom relief after TAVI and may indicate when intervention is likely to be futile. Both low (<800 ng/L) and very high (>10 000 ng/L) levels are strongly associated with poor functional outcome, suggesting an alternative cause for symptoms in the former scenario and an irrevocably diseased left ventricle in the latter. Further evaluation of this relationship is warranted.

Predictors and Biomarkers of Subclinical Leaflet Thrombosis after Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is a recent revolutionary treatment for high-risk patients with severe aortic stenosis who are not suitable for surgery, expanding to intermediate and low-risk patients. Valve leaflet thrombosis (LT) is a potentially fatal complication after TAVI. The incidence of subclinical LT is as high as 25% among patients in the first year after TAVI. Subclinical LT may evolve into symptomatic thrombosis or lead to premature bioprosthesis degeneration, increasing the risk of neurological complications. Because imaging-based methods have limited sensitivity to detect subclinical LT, there is an urgent need for predictors and biomarkers that would make it possible to predict LT after TAVI. Here, we summarize recent data regarding (i) patient-related, (ii) procedure-related, (iii) blood-based and (iv) imaging predictors and biomarkers which might be useful for the early diagnosis of subclinical LT after TAVI. Prevention of LT might offer an opportunity to improve risk stratification and tailor therapy after TAVI.

Pre- and Post-Transcatheter Aortic Valve Replacement Serum Brain Natriuretic Peptide Levels and All-Cause Mortality

BACKGROUND

Risk stratification in patients post-transcatheter aortic valve replacement (TAVR) is limited to and is based on clinical judgment and surgical scoring systems. Serum natriuretic peptides are used for general risk stratification in patients with aortic stenosis, reflecting the increase in their afterload and thereby stressing the need for valve intervention. The objective of this study was to determine the predictive value of pre- and post-procedural serum brain natriuretic peptide (BNP) on 1-year all-cause mortality in patients who underwent TAVR.

METHODS

In this population-based study, we included 148 TAVR patients treated at the Poriya Medical Center between June 1, 2015, and May 31, 2018. Routine blood samples for serum BNP levels (pg/mL) were taken just before the TAVR and 24 h post-TAVR. Our primary clinical outcome was defined as 1-year all-cause mortality. We used backward regression models and included all variables that had a p value <0.1 in the univariable analysis. A receiver-operating characteristic curve was calculated for the prediction of all-cause mortality by serum BNP levels using the median as the cut-off point.

RESULTS

In this study cohort, BNP levels 24 h post-TAVR higher than the cohort median versus lower than the cohort median (387.5 pg/mL; IQR 195-817.6) were the strongest predictor of 1-year mortality (hazard ratio 9; 95% CI 2.72-30.16; p < 0.001). The statistically significant relationship was seen in the unadjusted regression model as well as after the adjustment for clinical variables.

CONCLUSIONS

Serum BNP levels 24 h post-procedure were found to be a meaningful marker in predicting 1-year all-cause mortality in patients after TAVR procedure.

Impact of Loop Diuretic Use on Outcomes Following Transcatheter Aortic Valve Implantation

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

Periprocedural Changes of NT-proBNP Are Associated With Survival After Transcatheter Aortic Valve Implantation

Background

Cardiovascular biomarkers constitute promising tools for improved risk stratification and prediction of outcome in patients undergoing transcatheter aortic valve implantation. We examined the association of periprocedural changes of NT‐proBNP (N‐terminal pro–B‐type natriuretic peptide) with survival after transcatheter aortic valve implantation.

Methods and Results

NT‐proBNP levels were measured in 704 patients before transcatheter aortic valve implantation and at discharge. Patients were grouped as responders and nonresponders depending on an NT‐proBNP–based ratio (postprocedural NT‐proBNP at discharge/preprocedural NT‐proBNP). Overall, 376 of 704 patients showed a postprocedural decrease in NT‐proBNP levels (NT‐proBNP ratio <1). Responders and nonresponders differed significantly regarding median preprocedural (2822 versus 1187 pg/mL, P<0.001) and postprocedural (1258 versus 3009 pg/mL, P<0.001) NT‐proBNP levels. Patients in the nonresponder group showed higher prevalence of atrial fibrillation (47.0% versus 39.4%, P=0.042), arterial hypertension (94.2% versus 87.5%, P=0.002), renal impairment (77.4% versus 69.1%, P=0.013), and peripheral artery disease (24.4% versus 14.6%, P=0.001). In contrast, patients in the responder group had higher prevalence of moderately reduced left ventricular ejection fraction (17.3% versus 11.0%, P=0.017), lower calculated aortic valve area (0.7 versus 0.8 cm², P<0.001), and higher mean pressure gradient (41 versus 35 mm Hg, P<0.001). Median follow‐up was 22.6 months. Kaplan–Meier analysis showed a highly significant survival benefit for the responder group compared with the nonresponder group (log‐rank test, P<0.001).

Conclusions

A ratio based on periprocedural changes of NT‐proBNP is a simple tool for better risk stratification and is associated with survival in patients after transcatheter aortic valve implantation.

Low and elevated B-type natriuretic peptide levels are associated with increased mortality in patients with preserved ejection fraction undergoing transcatheter aortic valve replacement: an analysis of the PARTNER II trial and registry

Aims

B-type natriuretic peptide (BNP) is a cardiac neurohormone that is secreted in response to ventricular volume expansion and pressure overload. There are conflicting data regarding the association between BNP levels and outcomes after transcatheter aortic valve replacement (TAVR). We therefore sought to assess the association between baseline BNP and adverse outcomes in patients with symptomatic, severe aortic stenosis (AS), and left ventricular ejection fraction (LVEF) ≥50%, undergoing TAVR in the PARTNER 2 Trial and Registry.

Methods and results

A total of 1782 patients were included in the analysis, and BNP was evaluated both as a continuous log-transformed value and by a priori categories: low (&lt;50 pg/mL), normal (≥50 and &lt;100 pg/mL), moderately elevated (≥100 and &lt;400 pg/mL), or markedly elevated (≥400 pg/mL). Clinical outcomes from discharge to 2 years were compared between patients according to their baseline BNP level, using Kaplan–Meier event rates and multivariable Cox proportional hazards regression models. After adjustment, spline curves revealed a non-linear association between log-transformed BNP and all-cause and cardiovascular mortality in which both the lowest and highest values were associated with increased mortality. Two-year all-cause mortality rates for those with low (n = 86), normal (n = 202), moderately elevated (n = 885), and markedly elevated (n = 609) baseline BNP were 20.0%, 9.8%, 17.7%, and 26.1%, respectively. In adjusted models, compared to a normal baseline BNP, low [adjusted hazard ratio (HR) 2.6, 95% confidence interval (CI) 1.3–5.0, P-value 0.005], moderately elevated (adjusted HR 1.6, 95% CI 1.0–2.6, P-value 0.06), and markedly elevated (adjusted HR 2.1, 95% CI 1.3–3.5, P-value 0.003) BNP were associated with increased all-cause mortality, driven by cardiovascular mortality.

Conclusions

In a large cohort of patients with severe symptomatic AS and preserved LVEF undergoing TAVR, all-cause and cardiovascular mortality rates at 2 years were higher in patients with low and markedly elevated BNP levels.

Clinical Trial Registration

https://clinicaltrials.gov/ unique identifier #NCT01314313, #NCT02184442, #NCT03222128, and #NCT03222141.

Outcome of patients with heart failure after transcatheter aortic valve implantation

AIMS

Patients with aortic stenosis (AS) may have concomitant heart failure (HF) that determines prognosis despite successful transcatheter aortic valve implantation (TAVI). We compared outcomes of TAVI patients with low stroke volume index (SVI) ≤35 ml/m2 body surface area in different HF classes.

METHODS AND RESULTS

Patients treated by transfemoral TAVI at our center (n = 1822) were classified as 1) 'HF with preserved ejection fraction (EF)' (HFpEF, EF ≥50%), 2) 'HF with mid-range EF' (HFmrEF, EF 40-49%), or 3) 'HF with reduced EF' (HFrEF, EF <40%). Patients with SVI >35 ml/m2 served as controls. The prevalence of cardiovascular disease and symptoms increased stepwise from controls (n = 968) to patients with HFpEF (n = 591), HFmrEF (n = 97), and HFrEF (n = 166). Mortality tended to be highest in HFrEF patients 30 days post-procedure, and it became significant after one year: 10.2% (controls), 13.5% (HFpEF), 13.4% (HFmrEF), and 23.5% (HFrEF). However, symptomatic improvement in survivors of all groups was achieved in the majority of patients without differences among groups.

CONCLUSIONS

Patients with AS and HF benefit from TAVI with respect to symptom alleviation. TAVI in patients with HFpEF and HFmrEF led to an identical, favorable post-procedural prognosis that was significantly better than that of patients with HFrEF, which remains a high-risk population.

Prognostic implications of N-terminal pro-B-type natriuretic peptide in patients with normal left ventricular ejection fraction undergoing transcatheter aortic valve implantation

BACKGROUND

Biomarkers may significantly improve risk stratification algorithms for patients undergoing transcatheter aortic valve implantation (TAVI). While N-terminal pro-B-type natriuretic peptide (NT-proBNP) is established as a biomarker in the context of heart failure, its prognostic implications in patients with normal left ventricular ejection fraction (LVEF) undergoing TAVI are unclear.

METHODS

A total of 504 TAVI patients with normal LVEF were analyzed. Based on preprocedural NT-proBNP levels, patients were stratified into two groups comparing the upper quartile ("Q4", n = 126) with the lower three quartiles ("Q1-3", n = 378). The primary outcome of our study was survival.

RESULTS

The "Q4" group included more men (46.8% vs. 34.9%, p = 0.017), had higher rates of atrial fibrillation (55.6% vs. 28.3%, p < 0.001) and showed features of more advanced aortic stenosis (mean pressure gradient 49 mmHg vs. 40 mmHg, aortic valve area 0.6 cm² vs. 0.7 cm²; p < 0.001, respectively). The "Q4" group was also characterized by more extensive cardiac remodeling including severe diastolic dysfunction (18.1% vs. 6.5%, p < 0.001) and left atrial dilation (26.8% vs. 10.8%, p < 0.001). Kaplan-Meier analysis demonstrated superior survival of the "Q1-3" group (median follow-up 22.1 months, log-rank test p < 0.001). In a multivariable analysis, preprocedural NT-proBNP emerged as a significant risk factor for all-cause mortality after TAVI (HR 1.87, CI 1.31-2.65, p < 0.001).

CONCLUSIONS

NT-proBNP is associated with survival in TAVI patients with normal LVEF. In this patient group, preprocedural NT-proBNP levels do not only correlate with aortic stenosis, but reflect advanced cardiovascular dysfunction, including HFpEF, that might not be completely reversible after TAVI.

Impact of diastolic dysfunction on long-term mortality and quality of life after transcatheter aortic valve replacement

BACKGROUND

There is conflicting data as to whether diastolic dysfunction (DD) affects the prognosis of patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Consecutive patients undergoing TAVR underwent assessment of DD with preoperative echocardiography and NT-pro BNP. Long-term survival was ascertained every 6 months by clinic visits or phone. DD was graded according to the new American Society of Echocardiography recommendations. Health status was assessed at baseline and 30 days post-procedure using the KCCQ-12 questionnaire. Long-term survival was displayed using Kaplan-Meier curves according to NT-pro BNP levels and DD grades.

RESULTS

We included 222 patients, mean age 78 (±8) years, median STS score 4 (interquartile range = 3-7), median follow-up time 385 days (IQR = 180-640). DD was absent in 25, Grade I in 13, Grade II in 74, Grade III in 24, and indeterminate in 86 patients. Advanced (Grades II-III) DD was associated with higher pre-procedural NT-pro BNP levels (p < .001), worse quality of life (p < .001) but similar surgical risk (p = .43). Advanced and indeterminate DD were associated with increased long-term mortality (25-28% vs. 5%, p = .02) and elevated NT-pro BNP levels (26.4% vs. 9.8%, p = .05). Improvements in quality of life measures were seen in all DD groups (median change in KCCQ score no or Grade I DD:14 [3-21] vs. Grades II-III DD: 15 [16-26; p = .37]).

CONCLUSION

Preoperative NT-pro BNP levels and echocardiographic indices of indeterminate or advanced DD are associated with increased long-term mortality after TAVR but similar improvements in quality of life.

Meta-Analysis of Impact of Baseline N-TerminalPro-Brain Natriuretic Peptide Levels on SurvivalAfter Transcatheter Aortic Valve Implantation for Aortic Stenosis

We performed a meta-analysis of currently available studies investigating impact of baseline N-terminal pro-brain natriuretic peptide (NT-proBNP) on mortality after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). MEDLINE and EMBASE were searched through August 2018 using PubMed and OVID. Studies considered for inclusion met the following criteria: the design was a study researching impact of baseline NT-proBNP levels on survival; the study population was patients underwent TAVI for AS; outcomes included all-cause mortality. For each study, we directly extracted odds ratio (ORs) or hazard ratios (HRs) of mortality (for high vs low baseline NT-proBNP); and generated ORs using mortality rates in both patients with high and low levels of baseline NT-proBNP. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. We identified 16 eligible studies including a total of 3,679 patients who underwent TAVI for AS. Pooled analyses demonstrated that high levels of baseline NT-proBNP were associated with a statistically nonsignificant increase in early (30-day or 2-month) mortality (pooled OR, 1.60; 95% confidence interval, 0.84 to 3.04; p = 0.15) and a statistically significant increase in midterm (6-month to 4-year) mortality (pooled OR/HR, 1.88; 95% confidence interval, 1.54 to 2.28; p < 0.00001). Although funnel-plot asymmetry suggesting publication bias was detected, adjusting for funnel-plot asymmetry indicated an association of high levels of baseline NT-proBNP with a still significant increase in midterm mortality. In conclusion, high levels of baseline NT-proBNP predict increased midterm, not early, mortality after TAVI for AS.

Early changes in N-terminal pro-B-type natriuretic peptide levels after transcatheter aortic valve replacement and its impact on long-term mortality

BACKGROUND

N-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) levels correlate with higher peri-procedural mortality after transcatheter aortic valve replacement (TAVR). The long-term prognostic value of NT-proBNP within the first days after TAVR, however, remains unclear. This study examined early changes in NT-proBNP prior to and within 6 days after TAVR, the diagnostic value of this biomarker regarding aortic regurgitation (AR), and its prognostic value regarding one-year mortality.

METHODS AND RESULTS

NT-proBNP concentrations were measured in 504 consecutive patients undergoing transapical (TA) or transfemoral (TF) TAVR before and directly after TAVR as well as 4 h and 1, 2, 3, and 6 days after TAVR. The follow-up period was 1 year. NT-proBNP was elevated in all patients at baseline (median 2141 ng/L [IQR 1021-5319 ng/L]). NT-proBNP changes in the first 6 days after TAVR showed significant differences depending on the approach, with a greater and more prolonged rise evident in TA-TAVR patients. NT-proBNP was an independent predictor of mortality in TA patients with AR, with an AUC of 0.794 (95% CI 0.663-0.925; P = 0.003) when measured on day 3 after TAVR. For TF patients with AR and reduced left ventricular systolic function, the AUC for prediction of mortality was 0.897 (95% CI 0.778-1.0; P = 0.004) on day 2.

CONCLUSIONS

The prognostic information of early post-procedural NT-proBNP concentrations is superior to pre-procedural values regarding all-cause mortality within 1 year. Post-procedural NT-proBNP must be interpreted in relation to the TAVR approach. NT-proBNP predicts mortality in TF-TAVR patients with AR and reduced left ventricular function.

Is elevation of N-terminal pro-B-type natriuretic peptide at discharge associated with 2-year composite endpoint of all-cause mortality and heart failure hospitalisation after transcatheter aortic valve implantation? Insights from a multicentre prospective OCEAN-TAVI registry in Japan

OBJECTIVES

The aim of this study was to investigate the 2-year prognostic impact of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at discharge following transcatheter aortic valve implantation (TAVI).

DESIGN

Multicentre prospective observational study.

SETTINGS

Seven institutions from multicentre, observational registry of symptomatic patients with severe aortic stenosis who undergo TAVI.

PARTICIPANTS

We enrolled 500 consecutive patients who underwent TAVI with measurements of NT-proBNP at discharge between 2013 and 2016. Study patients were stratified into two groups according to survival classification and regression tree (CART) analysis: high versus low NT-proBNP groups.

INTERVENTIONS

The impact of high NT-proBNP on a 2-year composite endpoint consisting of all-cause mortality and heart failure hospitalisation was evaluated using a multivariable Cox model.

RESULTS

Median age was 86 years (quartile 82-89), and 24.2% of the study population were men. Median Society of Thoracic Surgeon score was 7.1 (5.1-9.8), and NT-proBNP at discharge was 1381 (653-3136) pg/mL. The composite endpoint incidence was 13.0% (95% CI 9.5% to 16.3%) at 1 year and 22.3% (95% CI 16.1%-27.9%) at 2 years. The survival CART analysis revealed that the NT-proBNP level required to discern the 2-year composite endpoint was 4288 pg/mL. Elevated NT-proBNP had a statistically significant impact on outcomes, with adjusted HR of 2.21 (95% CI 1.21 to 4.04, p=0.010), and with a significant sex difference (P for interaction=0.003).

CONCLUSION

Elevation of NT-proBNP at discharge is associated with higher incidence of the 2-year composite endpoint after TAVI.

TRIAL REGISTRATION NUMBER

000020423.

Rise and fall of NT-proBNP in aortic valve intervention

Objectives

To describe the dynamics of N-terminal pro-B-type natriuretic peptide (NT-proBNP) from preoperative evaluation to 6-month follow-up in patients undergoing aortic valve intervention, and to evaluate NT-proBNP with regard to 1-year mortality.

Methods

At preoperative evaluation, we prospectively included 462 patients accepted for aortic valve intervention. The median time to surgical aortic valve replacement (SAVR; n=336) or transcatheter aortic valve implantation (TAVI; n=126) was 4 months. NT-proBNP was measured at enrolment for preoperative evaluation, on the day of surgery, postoperatively on day 1, day 3 and at the 6-month follow-up. Subgroups of patients undergoing SAVR with aortic regurgitation and aortic stenosis with and without coronary artery bypass were also analysed.

Results

NT-proBNP remained stable in all subgroups during the preoperative waiting period, but displayed a substantial transient early postoperative increase with a peak on day 3 except in the TAVI group, which peaked on day 1. At the 6-month follow-up, NT-proBNP had decreased to or below the preoperative level in all groups. In the SAVR group, NT-proBNP preoperatively and on postoperative days 1 and 3 revealed significant discriminatory power with regard to 1-year mortality (area under the curve (AUC)=0.79, P=0.0001; AUC=0.71, P=0.03; and AUC=0.79, P=0.002, respectively). This was not found in the TAVI group, which had higher levels of NT-proBNP both preoperatively and at the 6-month follow-up compared with the SAVR group.

Conclusions

The dynamic profile of NT-proBNP differed between patients undergoing TAVI and SAVR. NT-proBNP in the perioperative course was associated with increased risk of 1-year mortality in SAVR but not in TAVI.

Comparison of Carbohydrate Antigen 125 and N-Terminal Pro-Brain Natriuretic Peptide for Risk Prediction After Transcatheter Aortic Valve Implantation

Elevated carbohydrate antigen 125 (CA125) and N-terminal pro-brain natriuretic peptide (NTproBNP) have been associated with adverse outcome after transcatheter aortic valve implantation (TAVI). This study performs a comparison of both biomarkers for prognosis after TAVI. The study includes 363 patients. The primary end point was all-cause death or readmission for worsening congestive heart failure within 1 year after TAVI, and this end point occurred in 16% of the population. The optimal cutoff to predict the primary end point was 18.4 U/ml for CA125 and 2,570 ng/L for NTproBNP. Elevated CA125 levels were present in 52% and were associated with a higher rate of the primary end point (27% vs 3%; p <0.001). In parallel, elevated NTproBNP levels were present in 42% and were also associated with a higher rate of the primary end point (27% vs 8%; p <0.001). After multivariable adjustment, elevated CA125 (hazard ratio [HR] 5.26; p <0.001) and elevated NTproBNP (HR 2.12; p = 0.022) were independent predictors of the primary end point. To explore the utility of combining both biomarkers, CA125 was added to the model containing baseline variables and NTproBNP. Elevated CA125 (HR 4.62; p = 0.001), but not NTproBNP (HR 1.58; p = 0.194), persisted as an independent predictor of the primary end point. Addition of CA125 significantly improved the predictive capability of the model (C-statistic: 0.805 vs 0.776) and the net reclassification index (50%, 95% confidence interval [20 to 84]) with an integrated discriminative improvement of 3.0%. In conclusion, elevated CA125 and NTproBNP predict adverse clinical outcome after TAVI. However, when combining both biomarkers, the predictive capacity of CA125 was superior.

Acute Heart Failure at the Time of Transcatheter Aortic Valve Replacement Does not Increase Mortality

Objective

Patients presenting for transcatheter aortic valve replacement are often in acute on chronic heart failure, as indicated by elevated N-terminal pro-B-type natriuretic peptide. Many believe that elevated N-terminal pro-B-type natriuretic peptide is an indication to treat medically, reserving surgery until the patient is medically optimized.

Methods

A single-center transcatheter aortic valve replacement database was queried from December 2015 to November 2016 to identify patients undergoing transcatheter aortic valve replacement. Patients were divided into two cohorts based on preoperative N-terminal pro-B-type natriuretic peptide level. An analysis was then completed to assess outcomes such as length of intensive care unit stay, total length of stay, discharge to home, major complications, and mortality at 30 days.

Results

There were 142 patients (median age = 80 years, 44% female) with preoperative N-terminal pro-B-type natriuretic peptide data included (range = 106–73,500 pg/mL). The mean Society of Thoracic Surgeons predicative risk of mortality was 8%, and 46 patients (32%) had N-terminal pro-B-type natriuretic peptide of greater than 3000 pg/mL. N-terminal pro-B-type natriuretic peptide of greater than 3000 pg/mL was associated only with increased intensive care unit length of stay of greater than 24 hours (35% vs 9%, P = 0.0001). There was no statistical difference between cohorts with regard to total length of stay of greater than 3 days (24% vs 15%, P = 0.2), discharge to home (74% vs 83%, P = 0.3), major complication, or mortality at 30 days.

Conclusions

Transcatheter aortic valve replacement is an appropriate and effective treatment for patients with aortic stenosis presenting with high N-terminal pro-B-type natriuretic peptide and acute on chronic heart failure.

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

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.

Effect of B-type natriuretic peptides on long-term outcomes after transcatheter aortic valve implantation

B-type natriuretic peptide (BNP) levels are elevated in patients with aortic stenosis (AS) and decrease acutely after replacement of the stenotic valve. The long-term prognostic value of BNP after transcatheter aortic valve implantation (TAVI) and the relative prognostic utility of single versus serial peri-interventional measurements of BNP and N-terminal prohormone BNP (NT-pro-BNP) are unknown. This study sought to determine the impact of BNP levels on long-term outcomes after TAVI and to compare the utility of BNP versus NT-pro-BNP measured before and after intervention. We analyzed 340 patients with severe AS and baseline pre-TAVI assessment of BNP. In 219 patients, BNP and NT-pro-BNP were measured serially before and after intervention. Clinical outcomes over 2 years were recorded. Patients with high baseline BNP (higher tertile ≥591 pg/ml) had increased risk of all-cause mortality (adjusted hazard ratio 3.16, 95% confidence interval 1.84 to 5.42; p <0.001) and cardiovascular death at 2 years (adjusted hazard ratio 3.37, 95% confidence interval 1.78 to 6.39; p <0.001). Outcomes were most unfavorable in patients with persistently high BNP before and after intervention. Comparing the 2 biomarkers, NT-pro-BNP levels measured after TAVI showed the highest prognostic discrimination for 2-year mortality (area under the curve 0.75; p <0.01). Baseline-to-discharge reduction, but not baseline levels of BNP, was related to New York Heart Association functional improvement. In conclusion, high preintervention BNP independently predicts 2-year outcomes after TAVI, particularly when elevated levels persist after the intervention. BNP and NT-pro-BNP and their serial periprocedural changes provide complementary prognostic information for symptomatic improvement and survival.

Coexisting Mitral Regurgitation Impairs Survival After Transcatheter Aortic Valve Implantation

BACKGROUND

It remains unclear whether coexisting and untreated mitral regurgitation (MR) affects survival after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). To summarize contemporary evidence, we performed the first metaanalysis of adjusted observational studies reporting post-TAVI mortality in patients with various grades of MR.

METHODS

MEDLINE and EMBASE were searched until February 2015, with a bibliographic review of secondary sources. Eligible studies were observational studies enrolling patients undergoing TAVI for AS and reporting adjusted odds ratios (ORs), hazard ratios (HRs), or both for early (30-day or in-hospital) all-cause mortality, overall all-cause mortality, or both in patients with apparent (significant) versus unapparent (nonsignificant) MR as outcomes.

RESULTS

Sixteen eligible studies enrolling a total of 13,672 patients undergoing TAVI for AS were identified and included. Pooled analyses of eight studies (representing 9,356 patients) and 14 studies (representing 7,405 patients) respectively demonstrated a statistically significant increase in early (OR 2.17; 95% confidence interval [CI] 1.50 to 3.14; p < 0.0001) and overall all-cause mortality (HR 1.81; 95% CI 1.37 to 2.40; p < 0.0001) in patients with apparent relative to unapparent MR. The exclusion of any single study from the analyses did not substantively alter the overall results of our analyses, and there was no evidence of significant publication bias.

CONCLUSIONS

Coexisting and untreated apparent (usually moderate or severe) MR appears to be associated with an increase in both early and overall mortality after TAVI for AS.

Clinical Applications of Natriuretic Peptides in Assessment of Valvular Heart Disease

Biomarkers such as natriuretic peptides (NPs) have evolving clinical utility beyond the scope of heart failure. The role of NPs in the management of valvular heart disease is a growing area of investigation. NPs have much potential in the assessment of asymptomatic patients with hemodynamically significant valvular lesions who have traditionally been excluded from consideration of surgical intervention. NPs also have a role in the risk stratification of these patients as well as in routine surveillance and monitoring. Together with echocardiographic data and functional status, NPs are being incorporated into the management of valvular heart disease. In this review we examine the evidence for the role of natriuretic peptides in assessment of VHD.

Prognostic value of serial B-type natriuretic peptide measurement in transcatheter aortic valve replacement (from the PARTNER Trial)

B-type natriuretic peptide (BNP) levels have shown a correlation with outcomes in studies of aortic valve surgery. Results from multicenter trials of BNP in transcatheter aortic valve surgery (TAVR) are lacking. The aim of this study was to investigate the prognostic role of serial measurement of BNP in transfemoral TAVR. A total of 1,097 patients who underwent TAVR via transfemoral access were analyzed by tertile of baseline BNP. Of those, 933 with BNP levels at 30 days were divided into 2 groups on the basis of increases (334 patients) or decreases or no change (599 patients) in BNP compared with baseline. Patients in the low-tertile BNP group had a lower rate of death at 1 year than those in the higher tertile group (15.0% vs 23.0%, p<0.01) which was not significant in multivariate analysis. Over 1 year, BNP decreased from 1,258.13±2,988.33 to 594.37±1,087.30 (p<0.01) in the entire group. Patients in the BNP-rise group had higher rates of death at 1 year (20.3% vs 11.4%, p<0.01) and an overall increase in moderate or severe aortic regurgitation over 1 year (p<0.01). Multivariate predictors of 1-year mortality were moderate or severe aortic regurgitation (hazard ratio 2.04, 95% confidence interval 1.36 to 3.05, p<0.01), increase in BNP at 30 days (hazard ratio 1.82, 95% confidence interval 1.26 to 2.62, p<0.01) and Society of Thoracic Surgeons score (hazard ratio 1.05, 95% confidence interval 1.01 to 1.10, p=0.03). In conclusion, increase in BNP at 30 days from baseline and moderate or severe aortic regurgitation at 30 days in patients who undergo transfemoral TAVR are independently associated with 1-year mortality. Increase in BNP at 30 days should prompt evaluation for causes of elevated wall stress, including aortic regurgitation.