1
|
Xie RC, Wang YT, Lin XF, Lin XM, Hong XY, Zheng HJ, Zhang LF, Huang T, Ma JF. Development and validation of a clinical prediction model for early ventilator weaning in post-cardiac surgery. Heliyon 2024; 10:e28141. [PMID: 38560197 PMCID: PMC10979061 DOI: 10.1016/j.heliyon.2024.e28141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
Background Weaning patients from mechanical ventilation is a critical clinical challenge post cardiac surgery. The effective liberation of patients from the ventilator significantly improves their recovery and survival rates. This study aimed to develop and validate a clinical prediction model to evaluate the likelihood of successful extubation in post-cardiac surgery patients. Method A predictive nomogram was constructed for extubation success in individual patients, and receiver operating characteristic (ROC) and calibration curves were generated to assess its predictive capability. The superior performance of the model was confirmed using Delong's test in the ROC analysis. A decision curve analysis (DCA) was conducted to evaluate the clinical utility of the nomogram. Results Among 270 adults included in our study, 107 (28.84%) experienced delayed extubation. A predictive nomogram system was derived based on five identified risk factors, including the proportion of male patients, EuroSCORE II, operation time, pump time, bleeding during operation, and brain natriuretic peptide (BNP) level. Based on the predictive system, five independent predictors were used to construct a full nomogram. The area under the curve values of the nomogram were 0.880 and 0.753 for the training and validation cohorts, respectively. The DCA and clinical impact curves showed good clinical utility of this model. Conclusion Delayed extubation and weaning failure, common and potentially hazardous complications following cardiac surgery, vary in timing based on factors such as sex, EuroSCORE II, pump duration, bleeding, and postoperative BNP reduction. The nomogram developed and validated in this study can accurately predict when extubation should occur in these patients. This tool is vital for assessing risks on an individual basis and making well-informed clinical decisions.
Collapse
Affiliation(s)
- Rong-Cheng Xie
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Yu-Ting Wang
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Xue-Feng Lin
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Xiao-Ming Lin
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Xiang-Yu Hong
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Hong-Jun Zheng
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Lian-Fang Zhang
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Ting Huang
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
| | - Jie-Fei Ma
- Department of Critical Care Medicine, Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361015, Fujian province, PR China
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 310000, PR China
| |
Collapse
|
2
|
Rao RA, Varghese SS, Ansari F, Rao A, Meng E, El-Diasty M. The Role of Natriuretic Peptides in Predicting Adverse Outcomes After Cardiac Surgery: An Updated Systematic Review. Am J Cardiol 2024; 210:16-36. [PMID: 37884264 DOI: 10.1016/j.amjcard.2023.09.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023]
Abstract
The increasing global burden of cardiovascular disease, particularly, in the aging population, has led to an increase in high-risk cardiac surgical procedures. The current preoperative risk stratification scores, such as the European System for Cardiac Operative Risk Evaluation and the Society for Thoracic Surgeons score, have limitations in their predictive accuracy and tend to underestimate the mortality risk in higher-risk populations. This systematic review aimed to evaluate the utility of natriuretic peptides, brain natriuretic peptide (BNP) and its precursor prohormone (N-terminal prohormone BNP), as predictive biomarkers for adverse outcomes after cardiac surgery. A comprehensive search strategy was performed, and 63 studies involving 40,667 patients who underwent major cardiac operations were included for data extraction. Preoperative levels of BNP and N-terminal prohormone BNP seemed to be associated with an increased risk of short- and long-term mortality, postoperative heart failure, kidney injury, and length of intensive care unit stay. However, their predictive value for postoperative arrhythmias and myocardial infarction was less established. Our findings suggest that natriuretic peptides may play an important role in risk prediction in patients who underwent cardiac surgery. The addition of these biomarkers to the existing clinical risk stratification strategies may enhance their predictive accuracy. However, this needs to be endorsed by data derived from wide-scale clinical trials.
Collapse
Affiliation(s)
- Reddi Ashwin Rao
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | | | - Farzan Ansari
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Aditya Rao
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Eric Meng
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Mohammad El-Diasty
- Harrington Heart and Vascular Institute, Cardiac Surgery Department, University Hospitals, Cleveland, Ohio.
| |
Collapse
|
3
|
Holm J, Vanky F, Svedjeholm R. Glutamate Infusion Reduces Myocardial Dysfunction after Coronary Artery Bypass Grafting According to NT-proBNP: Summary of 2 Randomized Controlled Trials (GLUTAmate for Metabolic Intervention in Coronary Surgery [GLUTAMICS I-II]). Am J Clin Nutr 2023; 118:930-937. [PMID: 37657522 DOI: 10.1016/j.ajcnut.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 08/14/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Glutamate is reported to enhance the recovery of oxidative metabolism and contractile function of the heart after ischemia. The effect appears to be blunted in diabetic hearts. Elevated plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) reflects myocardial dysfunction. In the GLUTAmate for Metabolic Intervention in Coronary Surgery (GLUTAMICS) II trial, the proportion of patients with diabetes had nearly doubled to 47% compared with the cohort used for sample size estimation, and a significant effect on the postoperative rise in NT-proBNP was only observed in patients without diabetes. OBJECTIVE We aimed to summarize the pooled NT-proBNP results from both GLUTAMICS trials and address the impact of diabetes. METHODS Data from 2 prospective, randomized, double-blind multicenter trials with similar inclusion criteria and endpoints were pooled. Patients underwent a coronary artery bypass grafting (CABG) ± valve procedure and had a left-ventricular ejection fraction of ≤0.30 or a European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) of ≥3.0 with at least 1 cardiac risk factor. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h was started 10-20 min before reperfusion and continued for 150 min. The primary endpoint was the difference between preoperative and day 3 postoperative NT-proBNP levels. RESULTS A total of 451 patients, 224 receiving glutamate and 227 controls, fulfilled the inclusion criteria. Glutamate was associated with a reduced primary endpoint (5344 ± 5104 ng/L and 6662 ± 5606 ng/L in glutamate and control groups, respectively; P = 0.01). Postoperative mortality at ≤30 d was 0.9% and 3.5% (P = 0.11), whereas stroke at ≤24 h was 0.4% and 2.6% in glutamate and control groups, respectively (P = 0.12). No adverse events related to glutamate were observed. A significant interaction regarding the primary endpoint was only detected between glutamate and insulin-treated diabetes groups (P = 0.04). Among patients without insulin-treated diabetes, the primary endpoint was 5047 ± 4705 ng/L and 7001 ± 5830 ng/L in the glutamate and control groups, respectively (P = 0.001). CONCLUSIONS Infusion of glutamate reduced the postoperative rise in NT-proBNP after CABG in medium- to high-risk patients. A significantly blunted effect was observed only in insulin-treated patients with diabetes. CLINICAL TRIAL DETAILS This trial was registered at www. CLINICALTRIALS gov as NCT02592824.
Collapse
Affiliation(s)
- Jonas Holm
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Sweden
| | - Farkas Vanky
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Sweden
| | - Rolf Svedjeholm
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Sweden.
| |
Collapse
|
4
|
Wang J, Liu H, Zeng J, Su X, Zhao Y, Zheng Z. Utility of Preoperative N-Terminal Pro-B-Type Natriuretic Peptide in the Prognosis of Coronary Artery Bypass Grafting. Am J Cardiol 2023; 201:131-138. [PMID: 37385164 DOI: 10.1016/j.amjcard.2023.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/07/2023] [Accepted: 05/29/2023] [Indexed: 07/01/2023]
Abstract
Although N-terminal pro-B-type natriuretic peptide (NT-proBNP) has been validated as a cardiovascular biomarker, its ability to predict long-term outcomes after coronary artery bypass grafting (CABG) has not been fully explored. We aimed to assess the prognostic value of NT-proBNP beyond clinical risk prediction tools, and its relevance to follow-up events and interactions with different treatment selections. The study included 11,987 patients who underwent CABG who underwent surgery between 2014 and 2018. The primary end point was all-cause mortality during follow-up, whereas the secondary end points included cardiac death and major adverse cardiac and cerebrovascular events, which comprised death, myocardial infarction, and ischemic cerebrovascular accident. We evaluated the associations between NT-proBNP levels and outcome and the added prognostic value of NT-proBNP to clinical tools. Patients were followed up for a median of 4.0 years. Higher preoperative NT-proBNP levels were significantly associated with all-cause mortality, cardiac death, and major adverse cardiac and cerebrovascular events (all p <0.001). These associations remained significant after the full adjustment. Integration of NT-proBNP into clinical tools significantly improved the prediction accuracy for all end points. We also found that patients with higher preoperative NT-proBNP levels benefited more from β blockers (p for interaction = 0.045). In conclusion, we demonstrated the prognostic value of NT-proBNP in risk stratification and personalized treatment decisions in patients who underwent CABG.
Collapse
Affiliation(s)
- Juncheng Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hanning Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntong Zeng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoting Su
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases
| | - Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
5
|
Comanici M, Nadarajah D, Katumalla E, Cyclewala S, Raja SG. Use of Preoperative Natriuretic Peptide in Predicting Mortality After Coronary Artery Bypass Grafting: A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00255-0. [PMID: 37210323 DOI: 10.1053/j.jvca.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/20/2023] [Accepted: 04/14/2023] [Indexed: 05/22/2023]
Abstract
The objective of this systematic review was to evaluate the current evidence on the utility of preoperative B-type natriuretic peptide (BNP) and N-terminal-pro B-type natriuretic peptide (NT-proBNP) in predicting short-term and long-term mortality after coronary artery bypass grafting (CABG). OVID MEDLINE, EMBASE, SCOPUS, and PUBMED were searched from 1946 to August 2022 using the following terms: "coronary artery bypass grafting" and "BNP" and "outcomes." Eligible studies included observational studies reporting the association between preoperative BNP and NT-proBNP levels and short- and long-term mortality after CABG. Articles were selected systematically, assessed for bias, and, when possible, meta-analyzed using a random effect model. After retrieving 53 articles, 11 were included for qualitative synthesis and 4 for quantitative meta-analysis. Studies included in this review showed that elevated preoperative natriuretic peptide levels, despite variable cut-offs, have been consistently shown to be associated with short- and long-term mortality after CABG. The median BNP cut-off value was 145.5 pg/mL (25th-75th percentile 95-324.25 pg/mL), and the mean NT-proBNP value was 765 ± 372 pg/mL. Compared to patients with normal natriuretic peptide levels, patients with elevated BNP and NT-proBNP presented higher mortality rates after CABG (odds ratio 3.96, 95% confidence interval 2.41-6.52; p < 0.00001). Preoperative BNP level is a powerful predictor of mortality in patients undergoing CABG. The measurement of BNP can add significant value to these patients' risk stratification and therapeutic decision-making.
Collapse
Affiliation(s)
- Maria Comanici
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
| | | | - Eve Katumalla
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shabnam Cyclewala
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| |
Collapse
|
6
|
Oi K, Arai H, Nagaoka E, Fujiwara T, Oishi K, Takeshita M, Anzai T, Mizuno T. Long-term outcomes of papillary muscle relocation anteriorly for functional mitral regurgitation. Interact Cardiovasc Thorac Surg 2022; 35:6709350. [PMID: 36130272 DOI: 10.1093/icvts/ivac245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/12/2022] [Accepted: 09/20/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES This study aimed to evaluate the outcomes of the patients who underwent restrictive annuloplasty (RA) plus papillary muscle relocation anteriorly (PMR-A) with the risk factors in mitral valve repair for functional mitral regurgitation (FMR). METHODS Eighty-six patients underwent mitral valve repair with RA for FMR. Thirty-five of them received additional bilateral papillary muscle relocation for severe leaflet tethering. The papillary muscles were relocated posteriorly (PMR-P) early in the study. Then, in the later period, the technique was modified to PMR-A, in which the papillary muscles were relocated anteriorly for 24 cases. The survival of the patients undergoing RA + PMR-A was examined retrospectively, adjusting for differences in patient background. RESULTS Twenty-three deaths were observed during the follow-up period out of the 86 cases. Independent preoperative risk factors for survival were left ventricular ejection fraction, patient age and B-type natriuretic peptide (BNP) level. Among the patients with BNP <1000 pg/ml, 5-year survival after RA plus PMR-A was 84.7%, while RA alone was 78.6% and RA + PMR-P 57.1%. Cox proportional hazards regression adjusted for the preoperative risk factors showed a significantly higher hazard ratio of RA + PMR-P to RA + PMR-A (12.77, P = 0.011), while the hazard ratio of RA alone to RA + PMR-A was not significantly different. Furthermore, reverse remodelling of the left ventricle was observed for 3 years only in RA + PMR-A. CONCLUSIONS Long-term survival for patients who underwent RA plus bilateral PMR-A was promising. Patients with significantly higher BNP had lower survival after valve repair for FMR.
Collapse
Affiliation(s)
- Keiji Oi
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiki Nagaoka
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuki Fujiwara
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiyotoshi Oishi
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masashi Takeshita
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tatsuhiko Anzai
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan
| |
Collapse
|
7
|
Holm J, Ferrari G, Holmgren A, Vanky F, Friberg Ö, Vidlund M, Svedjeholm R. Effect of glutamate infusion on NT-proBNP after coronary artery bypass grafting in high-risk patients (GLUTAMICS II): A randomized controlled trial. PLoS Med 2022; 19:e1003997. [PMID: 35533197 PMCID: PMC9126383 DOI: 10.1371/journal.pmed.1003997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 05/23/2022] [Accepted: 04/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Animal and human data suggest that glutamate can enhance recovery of myocardial metabolism and function after ischemia. N-terminal pro-brain natriuretic peptide (NT-proBNP) reflects myocardial dysfunction after coronary artery bypass surgery (CABG). We investigated whether glutamate infusion can reduce rises of NT-proBNP in moderate- to high-risk patients after CABG. METHODS AND FINDINGS A prospective, randomized, double-blind study enrolled patients from November 15, 2015 to September 30, 2020, with a 30-day follow-up at 4 academic cardiac surgery centers in Sweden. Patients underwent CABG ± valve procedure and had left ventricular ejection fraction ≤0.30 or EuroSCORE II ≥3.0. Intravenous infusion of 0.125 M L-glutamic acid or saline at 1.65 mL/kg/h started 10 to 20 minutes before releasing the aortic cross-clamp, then continued for another 150 minutes. Patients, staff, and investigators were blinded to the treatment. The primary endpoint was the difference between preoperative and day-3 postoperative NT-proBNP levels. Analysis was intention to treat. We studied 303 patients (age 74 ± 7 years; females 26%, diabetes 47%), 148 receiving glutamate group and 155 controls. There was no significant difference in the primary endpoint associated with glutamate administration (5,390 ± 5,396 ng/L versus 6,452 ± 5,215 ng/L; p = 0.086). One patient died ≤30 days in the glutamate group compared to 6 controls (0.7% versus 3.9%; p = 0.12). No adverse events linked to glutamate were observed. A significant interaction between glutamate and diabetes was found (p = 0.03). Among patients without diabetes the primary endpoint (mean 4,503 ± 4,846 ng/L versus 6,824 ± 5,671 ng/L; p = 0.007), and the incidence of acute kidney injury (11% versus 29%; p = 0.005) was reduced in the glutamate group. These associations remained significant after adjusting for differences in baseline data. The main limitations of the study are: (i) it relies on a surrogate marker for heart failure; and (ii) the proportion of patients with diabetes had almost doubled compared to the cohort used for the sample size estimation. CONCLUSIONS Infusion of glutamate did not significantly reduce postoperative rises of NT-proBNP. Diverging results in patients with and without diabetes agree with previous observations and suggest that the concept of enhancing postischemic myocardial recovery with glutamate merits further evaluation. TRIAL REGISTRATION ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT02592824. European Union Drug Regulating Authorities Clinical Trials Database (Eudra CT number 2011-006241-15).
Collapse
Affiliation(s)
- Jonas Holm
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Linköping, Sweden
| | - Gabriele Ferrari
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Health Care Research Center, Örebro University, Örebro, Sweden
| | - Anders Holmgren
- Heart Center and Department of Public Health and Clinical Medicine, Medicine, Umeå University, Umeå, Sweden
| | - Farkas Vanky
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Linköping, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Health Care Research Center, Örebro University, Örebro, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Health Care Research Center, Örebro University, Örebro, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rolf Svedjeholm
- Department of Thoracic and Vascular Surgery, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Medicine, Linköping University, Linköping, Sweden
- * E-mail:
| |
Collapse
|
8
|
Jiang H, Holm J, Friberg Ö, Vanky F, Vidlund M, Tajik B, Yang Y, Svedjeholm R. Utility of NT-proBNP as an objective marker of postoperative heart failure after coronary artery bypass surgery: a prospective observational study. Perioper Med (Lond) 2021; 10:21. [PMID: 34253255 PMCID: PMC8275184 DOI: 10.1186/s13741-021-00194-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/04/2021] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative heart failure (PHF) is the main cause for mortality after cardiac surgery but unbiased evaluation of PHF is difficult. We investigated the utility of postoperative NT-proBNP as an objective marker of PHF after coronary artery bypass surgery (CABG). Methods Prospective study on 382 patients undergoing isolated CABG for acute coronary syndrome. NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A blinded Endpoints Committee used prespecified criteria for PHF. Use of circulatory support was scrutinized. Results After adjusting for confounders PHF was associated with 1.46 times higher NT-proBNP on POD1 (p = 0.002), 1.54 times higher on POD3 (p < 0.0001). In severe PHF, NT-proBNP was 2.18 times higher on POD1 (p = 0.001) and 1.81 times higher on POD3 (p = 0.019). Postoperative change of NT-proBNP was independently associated with PHF (OR 5.12, 95% CI 1.86–14.10, p = 0.002). The use of inotropes and ICU resources increased with incremental quartiles of postoperative NT-proBNP. Conclusions Postoperative NT-proBNP can serve as an objective marker of the severity of postoperative myocardial dysfunction. Due to overlap in individuals, NT-proBNP is useful mainly for comparisons at cohort level. As such, it provides a tool for study purposes when an unbiased assessment of prevention or treatment of PHF is desirable. Trial registration ClinicalTrials.gov Identifier: NCT00489827https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00194-4.
Collapse
Affiliation(s)
- Huiqi Jiang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Jonas Holm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Farkas Vanky
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Mårten Vidlund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bashir Tajik
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden
| | - Yanqi Yang
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.,Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University of Medical Sciences, Guangzhou, Guangdong, China
| | - Rolf Svedjeholm
- Department of Cardiothoracic Surgery and Anesthesia, Faculty of Medicine and Health Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 85, Linköping, Sweden.
| |
Collapse
|
9
|
Lim JY, Jung SH, Choo SJ, Chung CH, Lee JW, Kim JB. B-type natriuretic peptide as a surrogate marker for survival in patients undergoing cardiac surgery. J Thorac Dis 2021; 13:955-967. [PMID: 33717568 PMCID: PMC7947500 DOI: 10.21037/jtd-20-2375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background B-type natriuretic peptide (BNP) is a biomarker predicting morbidity and mortality in patients with congestive heart failure. However, the usefulness of pre- or postoperative BNP levels in patients undergoing cardiac surgery remains uncertain. We sought to determine the association of pre- or postoperative BNP levels on mortality in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). Methods This study retrospectively evaluated 1,642 patients undergoing cardiac surgery under CPB over 2 years. The primary outcomes were 30-day and overall mortality after cardiac surgery. Results The 30-day mortality rate was 3.0% (n=49), and the overall mortality occurred in 118 patients during the mean follow-up period of 24.9±8.9 months. In multivariable analyses, preoperative BNP level was not significantly associated with 30-day [odds ratio (OR), 1.03; 95% confidence interval (CI), 0.99–1.06; P=0.06] or overall [hazard ratio (HR), 1.01; 95% CI, 0.98–1.03; P=0.50] mortalities. However, the postoperative BNP level was significantly associated with 30-day (OR, 1.05; 95% CI, 1.02–1.09; P=0.001) and overall (HR, 1.03; 95% CI, 1.01–1.04; P=0.01) mortalities. As a sensitivity analysis, postoperative BNP levels were divided into quartiles. The top quartile (≥484 pg/mL) was identified as a strong predictor of overall mortality (HR, 2.18; 95% CI, 1.14–4.19; P=0.02). Conclusions Preoperative BNP level was not associated with mortality after cardiac surgery. However, postoperative BNP level was associated with mortality after cardiac surgery, especially in patients with high levels (≥484 pg/mL). Further studies in larger cohorts are necessary to validate these results.
Collapse
Affiliation(s)
- Ju Yong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
10
|
Khurshaidi MN, Waqar A, Asghar MS, Kiran A, Tariq A, Kanwal N, Jawed R, Rasheed U, Hassan M, Mazhar A. Prognostic Value of Preoperative Pro-B-Type Natriuretic Peptide: Early Predictor of Cardiovascular Complications and Mortality After Major Abdominal Surgery. Cureus 2020; 12:e11338. [PMID: 33304674 PMCID: PMC7719483 DOI: 10.7759/cureus.11338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background and objectives In surgical patients, coronary disease is the main cause of perioperative mortality. The incidence of serious cardiovascular complications is reported as 5% with a probability of 1-2% of death from the cardiac cause in major non-cardiac surgery. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. The recent guidelines recommended the use of pro-BNP for independent perioperative prognosis in cardiac patients undergoing non-cardiac surgery. The aim of this study is to assess the predictive value of raised pro-BNP levels in patients who underwent major abdominal surgery and evaluate its relationship with cardiovascular complications and mortality occurring up to 30 days after surgery. Materials and methods We reviewed the medical records of patients undergone surgical procedures in the abdominal region lasting more than two hours, requiring postoperative high dependence or intensive care and an expected hospital stay of at least three days. All types of open or laparoscopic-assisted abdominal or pelvic surgeries that were evaluated for preoperative pro-BNP levels were included in the study. During the postoperative period, all patients were followed for cardiac complications and mortality for 30 days after surgery. Postoperative adverse cardiac events were predefined as angina pectoris, myocardial infarction, cardiogenic dyspnea, acute arrhythmias (atrial fibrillation/flutter, ventricular fibrillation/tachycardia), acute hypertensive event (hypertensive emergency or urgency), congestive heart failure, acute pulmonary edema, or primary cardiac death. While non-cardiac complications were also documented as either pulmonary, septic, postsurgical site infection, and other systemic complications. Subsequently, a survival analysis was done for the discretion of cardiovascular complications and mortality. Results The mean age of the study population was found to be 50.22 ± 14.28 years, mean pro-BNP levels were 909.29 ± 3950.04, and mean days of hospital stay were 7.43 ± 4.49 days. The 30-day postoperative all-cause mortality was found to be 9.8%. Hypertension and diabetes were frequent comorbidities amongst the study population. The mean preoperative pro-BNP levels were found higher in the male gender (p=0.071), also found higher in those with cardiovascular complications (p=0.006) and mortality (p=0.057). Receiver operating characteristic (ROC) analysis showed cardiovascular outcomes with a cut-off value of pro-BNP at 143 pg/ml, AUC of 0.891, at a sensitivity of 91%, positive predictive value (PPV) of 96%, a specificity of 75%, and negative predictive value (NPV) of 58%, while the same for mortality at a cut-off value of 164 pg/ml was found with AUC of 0.815, at a sensitivity of 84%, a specificity of 66%, PPV of 97%, and NPV of 21%. The unadjusted odds ratio for cardiovascular complications was found to be 17.857 (95% CI: 6.56-48.60) while that for mortality was 10.863 (95% Cl: 2.29-51.37). The Kaplan-Meier survival curves showing elevated pro-BNP levels were significantly associated with cardiovascular events, with 30 days mortality at a cut-off value of 164 pg/ml. Conclusion Pro-BNP is a useful marker in postoperative patients for not only predicting cardiovascular outcomes as cited by many previous studies but also mortality.
Collapse
Affiliation(s)
| | - Asad Waqar
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | | | - Afshan Kiran
- Internal Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari General Hospital, Karachi, PAK
| | - Asma Tariq
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Noureen Kanwal
- General Surgery, Liaquat National Hospital, Karachi, PAK
| | - Rumael Jawed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Uzma Rasheed
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Maira Hassan
- Internal Medicine, Liaquat National Hospital, Karachi, PAK
| | - Anees Mazhar
- Orthopaedics, Liaquat National Hospital, Karachi, PAK
| |
Collapse
|
11
|
Saran N. Commentary: The Holy Grail of Prognostic Biomarkers: One for Tricuspid Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 32:813-814. [PMID: 32615310 DOI: 10.1053/j.semtcvs.2020.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
12
|
Effect of BNP on risk assessment in cardiac surgery patients, in addition to EuroScore II. Sci Rep 2020; 10:10865. [PMID: 32616802 PMCID: PMC7331739 DOI: 10.1038/s41598-020-67607-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 06/05/2020] [Indexed: 12/28/2022] Open
Abstract
Patients' prognostication around cardiac surgery is key to better assess risk-benefit balance. Preoperative brain natriuretic peptide (BNP) biomarker has been associated with mortality after cardiac surgery, but its added value with EuroScore 2 remains to be confirmed. In a prospective registry cohort of 4,980 patients undergoing cardiac surgery, the prognostic performance of EuroScore 2 and preoperative BNP was assessed regarding postoperative in-hospital mortality. Discrimination feature was evaluated using receiver-operator-characteristics analysis with area under curve (AUROC). Calibration feature was assessed using Hosmer-Lemeshow test. Multivariable analysis was performed to assess the association between covariates and in-hospital mortality. In-hospital mortality was 3.7%. The AUROC of EuroScore 2 was 0.82 (95% confidence interval (95%CI) 0.79-0.85, p < 0.0001). The AUROC of BNP was 0.66 (95%CI 0.62-0.70, p < 0.0001). The combined model with an AUROC of 0.67 (95%CI 0.63-0.71, p = 0.0001) did not yield better AUROC than EuroScore 2 alone (p < 0.0001 in disfavor of the combined model), nor BNP alone (p = 0.79). In multivariable analysis, EuroScore 2 remained independently associated with mortality (adj.OR of 1.12 (1.10-1.14), p < 0.0001), but BNP was not. Preoperative BNP was not an independent risk factor of postoperative mortality and did not add prognostic information, as compared to EuroScore 2 alone.Clinical trial registry Registry for the Improvement of Postoperative OutcomeS in Cardiac and Thoracic surgEry (RIPOSTE) database (NCT03209674).
Collapse
|
13
|
Harrison TG, Shukalek CB, Hemmelgarn BR, Zarnke KB, Ronksley PE, Iragorri N, Graham MM, James MT. Association of NT-proBNP and BNP With Future Clinical Outcomes in Patients With ESKD: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:233-247. [PMID: 32387090 DOI: 10.1053/j.ajkd.2019.12.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/30/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE Use of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for cardiovascular (CV) risk assessment in patients with end-stage kidney disease (ESKD) remains unclear. We examined the associations between different threshold elevations of these peptide levels and clinical outcomes in patients with ESKD. STUDY DESIGN Systematic review and meta-analysis. SETTING & STUDY POPULATIONS We searched MEDLINE and EMBASE (through September 2019) for observational studies of adults with ESKD (estimated glomerular filtration rate≤15mL/min/1.73m2 or receiving maintenance dialysis). SELECTION CRITERIA FOR STUDIES Studies that reported NT-proBNP or BNP levels and future CV events, CV mortality, or all-cause mortality. DATA EXTRACTION Cohort characteristics and measures of risk associated with study-specified peptide thresholds. ANALYTICAL APPROACH Hazard ratios (HRs) for clinical outcomes associated with different NT-proBNP and BNP ranges were categorized into common thresholds and pooled using random-effects meta-analysis. RESULTS We identified 61 studies for inclusion in our review (19,688 people). 49 provided sufficient detail for inclusion in meta-analysis. Pooled unadjusted HRs for CV mortality were progressively greater for greater thresholds of NT-proBNP, from 1.45 (95% CI, 0.91-2.32) for levels>2,000pg/mL to 5.95 (95% CI, 4.23-8.37) for levels>15,000pg/mL. Risk for all-cause mortality was significantly higher at all NT-proBNP thresholds ranging from> 1,000 to> 20,000pg/mL (HR range, 1.53-4.00). BNP levels>550pg/mL were associated with increased risk for CV mortality (HR, 2.54; 95% CI, 1.49-4.33), while the risks for all-cause mortality were 2.04 (95% CI, 0.82-5.12) at BNP levels>100pg/mL and 2.97 (95% CI, 2.21-3.98) at BNP levels>550pg/mL. Adjusted analyses demonstrated similarly greater risks for CV and all-cause mortality with greater NT-proBNP concentrations. LIMITATIONS Incomplete outcome reporting and risk for outcome reporting bias. Estimation of risk for CV events for specific thresholds of both peptides were limited by poor precision. CONCLUSIONS ESKD-specific NT-proBNP and BNP level thresholds of elevation are associated with increased risk for CV and all-cause mortality. This information may help guide interpretation of NT-proBNP and BNP levels in patients with ESKD.
Collapse
Affiliation(s)
- Tyrone G Harrison
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Caley B Shukalek
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly B Zarnke
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Iragorri
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Matthew T James
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
14
|
The impact of glutamate infusion on postoperative NT-proBNP in patients undergoing coronary artery bypass surgery: a randomized study. J Transl Med 2020; 18:193. [PMID: 32393387 PMCID: PMC7216679 DOI: 10.1186/s12967-020-02351-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/25/2020] [Indexed: 12/28/2022] Open
Abstract
Background Glutamate, a key intermediate in myocardial metabolism, may enhance myocardial recovery after ischemia and possibly reduce the incidence and severity of postoperative heart failure in coronary artery bypass surgery (CABG). N-terminal pro-B-type natriuretic peptide (NT-proBNP) can be used to assess postoperative heart failure (PHF) after CABG. Our hypothesis was that glutamate enhances myocardial recovery in post-ischemic heart failure and, therefore, will be accompanied by a mitigated postoperative increase of NT-proBNP. Methods Substudy of the GLUTAmate for Metabolic Intervention in Coronary Surgery (GLUTAMICS) trial (ClinicalTrials.gov Identifier: NCT00489827) a prospective triple-center double-blind randomized clinical trial on 399 patients undergoing CABG with or without concomitant procedure for acute coronary syndrome at three Swedish Cardiac Surgery centres (Linköping, Örebro, and Karlskrona) from May 30, 2007 to November 12, 2009. Patients were randomly assigned to intravenous infusion of 0.125 M l-glutamic acid or saline (1.65 mL/kg of body weight per hour) intraoperatively and postoperatively. Plasma NT-proBNP was measured preoperatively, the first (POD1) and third postoperative morning (POD3). A Clinical Endpoints Committee, blinded to both intervention and NT-proBNP used prespecified criteria to diagnose PHF. The primary endpoints were the absolute levels of postoperative NT-proBNP and the difference between preoperative and postoperative levels of NT-proBNP. Results Overall no significant difference was detected in postoperative NT-proBNP levels between groups. However, in high-risk patients (upper quartile of EuroSCORE II ≥ 4.15; glutamate group n = 56; control group n = 45) glutamate was associated with significantly lower postoperative increase of NT-proBNP (POD3-Pre: 3900 [2995–6260] vs. 6745 [3455–12,687] ng•L−1, p = 0.012) and lower NT-proBNP POD3 (POD3: 4845 [3426–7423] vs. 8430 [5370–14,100] ng•L−1, p = 0.001). After adjusting for significant differences in preoperative demographics, NT-proBNP POD3 in the glutamate group was 0.62 times of that in the control group (p = 0.002). Patients in the glutamate group also had shorter ICU stay (21 [19–26] vs. 25 [22–46] h, p = 0.025) and less signs of myocardial injury (Troponin T POD3 (300 [170–500] vs. 560 [210–910] ng•L−1, p = 0.025). Conclusions Post hoc analysis of postoperative NT-proBNP suggests that intravenous infusion of glutamate may prevent or mitigate myocardial dysfunction in high-risk patients undergoing CABG. Further studies are necessary to confirm these findings. Trial registration Swedish Medical Products Agency 151:2003/70403 (prospectively registered with amendment about this substudy filed March 17, 2007). ClinicalTrials.gov Identifier: NCT00489827 (retrospectively registered) https://clinicaltrials.gov/ct2/show/NCT00489827?term=glutamics&draw=1&rank=1
Collapse
|
15
|
Free triiodothyronine (fT3) and B-type natriuretic peptide (BNP) predict in-hospital mortality after valve surgery. Gen Thorac Cardiovasc Surg 2019; 68:585-595. [DOI: 10.1007/s11748-019-01244-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023]
|
16
|
Brynildsen J, Myhre PL, Lyngbakken MN, Klaeboe LG, Stridsberg M, Christensen G, Edvardsen T, Omland T, Røsjø H. Circulating secretoneurin concentrations in patients with moderate to severe aortic stenosis. Clin Biochem 2019; 71:17-23. [PMID: 31228433 DOI: 10.1016/j.clinbiochem.2019.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/31/2019] [Accepted: 06/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Secretoneurin (SN) concentrations provide important prognostic information in patients with myocardial dysfunction. Whether preoperative SN concentrations improve risk assessment in patients with moderate to severe aortic stenosis (AS) is unknown. METHODS We included 57 patients with moderate to severe AS referred for presurgical evaluation. All patients were examined with comprehensive echocardiography, electrocardiogram (ECG), and biochemical measurements and compared to 10 age- and sex-matched healthy subjects. RESULTS Median (quartile 1-3) SN concentrations were 141 (121-163) pmol/L in AS patients and 132 (106-148) pmol/L in control subjects (p = .17). Lower estimated creatinine clearance and use of diuretics, but not standard ECG or echocardiographic indices and cardiac biomarkers, were associated with increasing SN concentrations. Fifteen patients (26%) died during 3.5 years median follow-up. SN concentrations were higher in non-survivors than survivors: 156 (133-209) vs. 140 (116-155) pmol/L, p = .007. Higher SN concentrations were associated with increased risk of mortality also after adjustment for established risk indices, biomarkers, and status regarding valvular surgery: hazard ratio per lnSN 15.13 (95% CI 1.05-219.00); p = .046. Receiver operating characteristics area under the curve for SN to predict mortality was 0.74 (95% CI 0.60-0.88) compared to 0.73 (0.59-0.87) for high-sensitivity cardiac troponin T and 0.67 (0.51-0.82) for N-terminal pro-B-type natriuretic peptide. The previously identified cut-off of SN >204 pmol/L in cardiac surgical patients predicted mortality also in this cohort. CONCLUSIONS SN concentrations improve risk assessment in patients with moderate to severe AS by providing additional prognostic information to established risk indices such as echocardiography, ECG, and established cardiac biomarkers.
Collapse
Affiliation(s)
- Jon Brynildsen
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magnus N Lyngbakken
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Gunnar Klaeboe
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Mats Stridsberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Geir Christensen
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Institute for Experimental Medical Research, Oslo University Hospital, Ullevål, Norway
| | - Thor Edvardsen
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway; Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Division of Research and Innovation, Akershus University Hospital, Lørenskog, Norway.
| |
Collapse
|
17
|
Jiang H, Vánky F, Hultkvist H, Holm J, Yang Y, Svedjeholm R. NT-proBNP and postoperative heart failure in surgery for aortic stenosis. Open Heart 2019; 6:e001063. [PMID: 31218010 PMCID: PMC6546186 DOI: 10.1136/openhrt-2019-001063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 04/22/2019] [Accepted: 04/26/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Postoperative heart failure (PHF) after aortic valve replacement (AVR) for aortic stenosis (AS) may initially appear mild and transient but has serious long-term consequences. Methods to assess PHF are not well documented. We studied the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and PHF after AVR for AS. Methods This is a prospective, observational, longitudinal study of 203 patients undergoing elective first-time AVR for AS. Plasma NT-proBNP was assessed at preoperative evaluation, the day before surgery, and the first (POD1) and third postoperative morning. A clinical endpoints committee, blinded to NT-proBNP results, used prespecified haemodynamic criteria to diagnose PHF. The mean follow-up was 8.6±1.1 years. Results No patient with PHF (n=18) died within 30 days after surgery, but PHF was associated with poor long-term survival (HR 3.01, 95% CI 1.45 to 6.21, p=0.003). NT-proBNP was significantly higher in patients with PHF only on POD1 (6415 (3145-11 220) vs 2445 (1540-3855) ng/L, p<0.0001). NT-proBNP POD1 provided good discrimination of PHF (area under the curve=0.82, 95% CI 0.72 to 0.91, p<0.0001; best cut-off 5290 ng/L: sensitivity 63%, specificity 85%). NT-proBNP POD1 ≥5290 ng/L identified which patients with PHF carried a risk of poor long-term survival, and PHF with NT-proBNP POD1 ≥ 5290 ng/L emerged as a risk factor for long-term mortality in the multivariable Cox regression (HR 6.20, 95% CI 2.72 to 14.1, p<0.0001). Conclusions The serious long-term consequences associated with PHF after AVR for AS were confirmed. NT-proBNP level on POD1 aids in the assessment of PHF and identifies patients at particular risk of poor long-term survival.
Collapse
Affiliation(s)
- Huiqi Jiang
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden.,Cardiothoracic Surgery, Sun Yat-sen University of Medical Sciences, Guangzhou, China
| | - Farkas Vánky
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden
| | - Henrik Hultkvist
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden
| | - Jonas Holm
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden
| | - Yanqi Yang
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden.,Cardiothoracic Surgery, Sun Yat-sen University of Medical Sciences, Guangzhou, China
| | - Rolf Svedjeholm
- Cardiothoracic and Vascular Surgery, Linköping University, Linkoping, Sweden
| |
Collapse
|
18
|
Krichevskiy LA, Kozlov IA. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care. J Cardiothorac Vasc Anesth 2018; 33:1407-1419. [PMID: 30228053 DOI: 10.1053/j.jvca.2018.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 01/16/2023]
Abstract
Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.
Collapse
Affiliation(s)
- Lev A Krichevskiy
- Department of Anesthesiology and Intensive Care, City Clinical Hospital n.a. S.S.Yudin, Department of Health of Moscow, Moscow, Russia.
| | - Igor A Kozlov
- Department of Anaesthesiology, Moscow Regional Research Clinical Institute n.a. M.F. Vladimirskiy, Moscow, Russia
| |
Collapse
|
19
|
Chan DXH, Sim YE, Chan YH, Poopalalingam R, Abdullah HR. Development of the Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator for prediction of postsurgical mortality and need for intensive care unit admission risk: a single-center retrospective study. BMJ Open 2018; 8:e019427. [PMID: 29574442 PMCID: PMC5875658 DOI: 10.1136/bmjopen-2017-019427] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/03/2018] [Accepted: 01/31/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Accurate surgical risk prediction is paramount in clinical shared decision making. Existing risk calculators have limited value in local practice due to lack of validation, complexities and inclusion of non-routine variables. OBJECTIVE We aim to develop a simple, locally derived and validated surgical risk calculator predicting 30-day postsurgical mortality and need for intensive care unit (ICU) stay (>24 hours) based on routinely collected preoperative variables. We postulate that accuracy of a clinical history-based scoring tool could be improved by including readily available investigations, such as haemoglobin level and red cell distribution width. METHODOLOGY Electronic medical records of 90 785 patients, who underwent non-cardiac and non-neuro surgery between 1 January 2012 and 31 October 2016 in Singapore General Hospital, were retrospectively analysed. Patient demographics, comorbidities, laboratory results, surgical priority and surgical risk were collected. Outcome measures were death within 30 days after surgery and ICU admission. After excluding patients with missing data, the final data set consisted of 79 914 cases, which was divided randomly into derivation (70%) and validation cohort (30%). Multivariable logistic regression analysis was used to construct a single model predicting both outcomes using Odds Ratio (OR) of the risk variables. The ORs were then assigned ranks, which were subsequently used to construct the calculator. RESULTS Observed mortality was 0.6%. The Combined Assessment of Risk Encountered in Surgery (CARES) surgical risk calculator, consisting of nine variables, was constructed. The area under the receiver operating curve (AUROC) in the derivation and validation cohorts for mortality were 0.934 (0.917-0.950) and 0.934 (0.912-0.956), respectively, while the AUROC for ICU admission was 0.863 (0.848-0.878) and 0.837 (0.808-0.868), respectively. CARES also performed better than the American Society of Anaesthesiologists-Physical Status classification in terms of AUROC comparison. CONCLUSION The development of the CARES surgical risk calculator allows for a simplified yet accurate prediction of both postoperative mortality and need for ICU admission after surgery.
Collapse
Affiliation(s)
| | - Yilin Eileen Sim
- Division of Anaesthesiology, Singapore General Hospital, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Hairil Rizal Abdullah
- Division of Anaesthesiology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
20
|
Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery. PLoS One 2018; 13:e0192503. [PMID: 29420603 PMCID: PMC5805306 DOI: 10.1371/journal.pone.0192503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/24/2018] [Indexed: 12/14/2022] Open
Abstract
Objective The primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality. Methods A retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures. Results Preoperative NT-proBNP was 1.67 times (p<0.0001) and 1.41 times (p<0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders. NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95%CI 0.73–0.85, p<0.0001), MR (AUC = 0.80, 95%CI 0.72–0.87, p<0.0001) and AS (AUC = 0.66, 95%CI 0.51–0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95%CI 0.71–0.85, p<0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD. Conclusions Patients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.
Collapse
|
21
|
Murad JA, Machado MN, Fernandes MP, Soares MJF, Grigolo IH, Singulane CC, Godoy MFD. B-Type Natriuretic Peptide as a Predictor of Short-Term Mortality in On-Pump Coronary Artery Bypass Grafting. Braz J Cardiovasc Surg 2017; 32:462-467. [PMID: 29267607 PMCID: PMC5731322 DOI: 10.21470/1678-9741-2017-0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 08/08/2017] [Indexed: 11/17/2022] Open
Abstract
Objective The present study refers to a determination of the preoperative B-type
natriuretic peptide is a predictor of short-term all-cause mortality in
patients undergoing on-pump coronary artery bypass graft surgeries. Methods Two hundred and twenty-one patients undergoing on-pump coronary artery bypass
graft surgeries were evaluated prospectively during a 30-day postoperative
follow-up period. Serum B-type natriuretic peptide concentration was
measured without a 24-hour period prior to the surgical procedure and the
value obtained was correlated with a short-term all-cause mortality. Results Data analysis showed that all-cause mortality rates were equal to 9.5% in 30
days. Accuracy analysis by the receiver operating characteristic curve found
an ideal cut-off value of B-type natriuretic peptide equal to 150 pg/mL in
relation to mortality (AUC=0.82, 95% CI=0.71-0.87,
P<0.001). Multivariate analysis showed that B-type
natriuretic peptide value greater than or equal to 150 pg/mL
(P=0.030, HR=3.99, 95% CI=1.14-13.98) was an
independent predictor of all-cause mortality in a 30-day follow-up
period. Conclusion Preoperative serum B-type natriuretic peptide concentration is an independent
predictor of short-term all-cause mortality in patients undergoing coronary
artery bypass grafting with cardiopulmonary bypass.
Collapse
Affiliation(s)
- Jamil Alli Murad
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | | | | | | | - Ingrid Helen Grigolo
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil
| | | | | |
Collapse
|
22
|
Mauermann E, Bolliger D, Fassl J, Grapow M, Seeberger EE, Seeberger MD, Filipovic M, Lurati Buse GAL. Absolute Postoperative B-Type Natriuretic Peptide Concentrations, but Not Their General Trend, Are Associated With 12-Month, All-Cause Mortality After On-Pump Cardiac Surgery. Anesth Analg 2017; 125:753-761. [PMID: 28753169 DOI: 10.1213/ane.0000000000002291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) is a predictor of mortality after on-pump cardiac surgery. However, previous limited and heterogeneous studies have focused on peak concentrations at 3 to 5 days after surgery and may not offer clinicians much help in early decision-making. After confirming the predictive value of first-postoperative-day BNP in a preliminary analysis, we explored the association between isolated second-postoperative-day BNP concentrations, second-day BNP concentrations in conjunction with first-day BNP concentrations, and the change in BNP (ie, ΔBNP) from the first to the second postoperative day and 12-month, all-cause mortality. METHODS We included consecutive patients undergoing on-pump cardiac surgery in this observational, secondary analysis of prospectively collected data. We analyzed biomarkers on the first and second postoperative day. ΔBNP was defined as BNP on the second postoperative day minus BNP on the first postoperative day. The primary end point was 12-month, all-cause mortality. The secondary end point was a composite of major adverse cardiac events (MACEs) at 12 months and/or all-cause mortality at 12 months. MACE was defined as nonfatal cardiac arrest, myocardial infarction, and congestive heart failure. The association between BNP and outcomes was examined by receiver operating characteristic curves, as well as univariate and multivariable logistic regression, adjusting for the EuroSCORE II, cross-clamp time, and first-postoperative-day troponin T. RESULTS We included 1199 patients in the preliminary analysis focused on BNP on postoperative day 1. In the analyses examining BNP variables requiring second-postoperative-day BNP measurement (n = 708), we observed 66 (9.3%) deaths, 48 (6.8%) MACE, and 104 (14.7%) deaths and/or MACE. Both first- and second-postoperative-day BNP were significant independent predictors of all-cause, 12-month mortality per 100 ng/L increase (adjusted odds ratio [aOR], 1.040 [95% confidence interval (CI), 1.019-1.065] and 1.064 [95% CI, 1.031-1.105], respectively). When used in conjunction with one another, first-day BNP was not significant (aOR, 1.021 [95% CI, 0.995-1.048]), while second-day BNP remained significant (aOR, 1.046 [95% CI, 1.008-1.091]). The ΔBNP per 100 ng/L increase was not associated with 12-month, all-cause mortality in the univariable (OR, 0.977 [95% CI, 0.951-1.007]) or multivariable analysis (aOR, 0.989 [95% CI, 0.962-1.021]). CONCLUSIONS Both absolute concentrations of first- and second-postoperative-day BNP are independent predictors of 12-month, all-cause mortality. When modeled together, second-postoperative-day BNP is more predictive of 12-month, all-cause mortality. Although intuitively appealing, the change in BNP from the first to the second postoperative day is a complex variable and should not routinely be used for prognostication.
Collapse
Affiliation(s)
- Eckhard Mauermann
- From the *Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, and †Department of Cardiac Surgery, Basel University Hospital, Basel, Switzerland; and ‡Basel University Medical School, Basel, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Pichette M, Liszkowski M, Ducharme A. Preoperative Optimization of the Heart Failure Patient Undergoing Cardiac Surgery. Can J Cardiol 2017; 33:72-79. [DOI: 10.1016/j.cjca.2016.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/27/2016] [Accepted: 08/01/2016] [Indexed: 02/02/2023] Open
|
24
|
B-type Natriuretic Peptide Predicts Morbidity and Long-Term Mortality in Coronary Artery Bypass Grafting and Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:439-443. [PMID: 27879531 DOI: 10.1097/imi.0000000000000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess whether B-type natriuretic peptide (BNP) levels are a useful predictor of morbidity and mortality as well as long-term survival in patients after coronary artery bypass grafting (CABG) and valve surgery. METHODS A retrospective review of CABG and/or valve surgery patients from 2012 to 2015 at a single center was conducted. A total of 432 patients were identified (CABG, 295 patients; valve, 82 patients; and CABG + valve, 55 patients). B-type natriuretic peptide levels were divided into quartiles (Q1-Q4). Mortality data were available for up to 3.4 years after surgery. RESULTS B-type natriuretic peptide quartile was independently associated with any complication on multivariate analysis. Patients in Q4 were at highest risk (adjusted odds ratio, 3.81; P = 0.047 vs Q1). There was a significant association between BNP quartile and time to death (log-rank χ, 8.30; P = 0.04) with greatest association 9 months postoperatively. B-type natriuretic peptide quartile was significantly associated with time to death in Cox regression in Q2 (hazard ratio [HR], 3.73 (1.04-13.44); P = 0.044) and Q4 (HR, 4.33 (1.14-16.44); P = 0.031). Q3 also had a higher risk of death (HR, 3.5 vs Q1); however, this was only significant at a trend level (P = 0.06). Using a risk model generated from logistic regression, we determined that the highest risk group had relative risk of complications 30 times higher than the lowest risk group. CONCLUSIONS B-type natriuretic peptide levels are an independent predictor of morbidity after CABG and/or valve surgery regardless of type of procedure or on/off bypass usage. B-type natriuretic peptide levels also correlate with time to death, highlighting the need for sustained follow-up and heart failure management to improve survival in patients with elevated BNP levels presenting for all cardiac surgery.
Collapse
|
25
|
Endicott KM, Amdur RL, Greenberg MD, Trachiotis GD. B-Type Natriuretic Peptide Predicts Morbidity and Long-Term Mortality in Coronary Artery Bypass Grafting and Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kendal M. Endicott
- Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, DC USA
| | - Richard L. Amdur
- Division of Cardiothoracic Surgery, The George Washington University, Washington, DC USA
| | | | - Gregory D. Trachiotis
- Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, DC USA
- Division of Cardiothoracic Surgery, The George Washington University, Washington, DC USA
| |
Collapse
|
26
|
Perioperative B-type Natriuretic Peptide/N-terminal pro-B-type Natriuretic Peptide. Anesthesiology 2015; 123:246-8. [DOI: 10.1097/aln.0000000000000729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
27
|
Barnet CS, Liu X, Body SC, Collard CD, Shernan SK, Muehlschlegel JD, Jarolim P, Fox AA. Plasma corin decreases after coronary artery bypass graft surgery and is associated with postoperative heart failure: a pilot study. J Cardiothorac Vasc Anesth 2014; 29:374-81. [PMID: 25649697 DOI: 10.1053/j.jvca.2014.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Corin is a natriuretic peptide-converting enzyme that cleaves precursor pro-B-type natriuretic peptide to active B-type natriuretic peptide (BNP) (diuretic, natriuretic, and vasodilatory properties). Increased plasma BNP is a known diagnostic and prognostic heart failure (HF) biomarker in ambulatory and surgical patients. Recent studies indicate that plasma corin is decreased significantly in chronic HF patients, yet perioperative plasma corin concentrations have not been assessed in cardiac surgical patients. The objectives of this study were to determine the effect of coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB) on plasma corin concentrations and to assess the association between change in perioperative plasma corin concentration and long-term postoperative HF hospitalization or death. It was hypothesized that plasma corin concentrations decrease significantly from preoperative baseline during postoperative days 1 to 4 and that hospitalization or death from HF during the 5 years after surgery is associated with higher relative difference (preoperative baseline to postoperative nadir) in plasma corin concentrations. DESIGN Prospective observational pilot study. SETTING Two institutions: Brigham and Women's Hospital, Boston, Massachusetts and the Texas Heart Institute, St. Luke's Hospital, Houston, Texas. PARTICIPANTS 99 patients of European ancestry who underwent isolated primary CABG surgery with CPB. INTERVENTIONS Nonemergency isolated primary CABG surgery with CPB. MEASUREMENTS AND MAIN RESULTS Plasma corin concentration was assessed preoperatively and at 4 postoperative time points (postoperative days 1-4). HF hospitalization or HF death events during the 5 years after surgery were identified by review of hospital and death records. Postoperative plasma corin concentrations were significantly lower than preoperative baseline concentrations (p<0.0001). Perioperative corin concentrations were significantly higher in males than in females (p<0.0001). Fifteen patients experienced long-term postoperative HF events. Patients who experienced HF hospitalization or HF death during study follow-up had significantly higher relative difference in plasma corin concentration (preoperative baseline to postoperative nadir) than patients who did not experience HF events during study follow-up (p=0.03). CONCLUSIONS Plasma corin concentrations decrease significantly from preoperative concentrations after CABG surgery. HF hospitalization or HF death during the 5 years after CABG surgery with CPB is associated with larger relative decrease in plasma corin concentration from preoperative baseline. Further investigation is warranted to determine the role of corin in postoperative HF biology.
Collapse
Affiliation(s)
- Caryn S Barnet
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Fairfax Anesthesia Associates of American Anesthesiology and Virginia Commonwealth University Medical School INOVA campus, Falls Church, Virginia.
| | - Xiaoxia Liu
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles D Collard
- Division of Cardiovascular Anesthesia, Texas Heart Institute, St. Luke's Hospital, Houston, TX
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
28
|
Holm J, Vidlund M, Vanky F, Friberg Ö, Håkanson E, Walther S, Svedjeholm R. EuroSCORE II and N-terminal pro-B-type natriuretic peptide for risk evaluation: an observational longitudinal study in patients undergoing coronary artery bypass graft surgery. Br J Anaesth 2014; 113:75-82. [DOI: 10.1093/bja/aeu088] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
29
|
Singh S, Kapoor A, Agarwal SK, Pande S, Sinha A, Rai H, Kumar S, Tewari S, Garg N, Majumdar G, Chandra B, Goel PK. Differential release kinetics of cardiac biomarkers in off-pump coronary bypass. Asian Cardiovasc Thorac Ann 2014; 22:674-81. [PMID: 24887882 DOI: 10.1177/0218492313504420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Differential release kinetics of the cardiac biomarkers (B-type natriuretic peptide, troponin I, and creatine kinase-MB) following off-pump coronary artery bypass are not well characterized. METHODS Biomarker levels were assessed at 6, 24, 48 h, and 1 month preoperatively, in 80 patients who underwent off-pump coronary artery bypass. RESULTS All biomarkers increased within 6 h of surgery. Peak B-type natriuretic peptide levels occurred at 24-48 h in 96% of patients, but only two-thirds had peak troponin I and creatine kinase-MB levels at this time, reflecting different release patterns. Levels of all biomarkers declined within 48 h, but 42% of patients still had B-type natriuretic peptide >100 pg·mL(-1) at 1 month. Those with baseline B-type natriuretic peptide > 100 pg·mL(-1) had a lower left ventricular ejection fraction (43.6% vs. 55.6%, p < 0.01) and longer inotropic (43.8 vs. 31.4 h, p = 0.03) and ventilator support (34 vs. 25.5 h, p = 0.04) than those with lower levels. B-type natriuretic peptide levels correlated positively with angiographic Syntax score (p = 0.02) and negatively with left ventricular ejection fraction (p < 0.001). Only baseline B-type natriuretic peptide predicted the durations of inotropic support (p = 0.01) and ventilation (p = 0.02). Postoperative B-type natriuretic peptide at 6, 24, and 48 h and delta B-type natriuretic peptide were significant predictors of mean ventilation time. CONCLUSION Even in patients undergoing off-pump surgery, there is significant natriuretic peptide and myocardial enzyme release. Only B-type natriuretic peptide levels had an association with postoperative variables.
Collapse
Affiliation(s)
- Satyajit Singh
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | - Aditya Kapoor
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | | | - Shantanu Pande
- Department of Cardiovascular Surgery, Sanjay Gandhi PGIMS, Lucknow, India
| | - Archana Sinha
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | - Himanshu Rai
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | - Sudeep Kumar
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | | | - Naveen Garg
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| | - Gauranga Majumdar
- Department of Cardiovascular Surgery, Sanjay Gandhi PGIMS, Lucknow, India
| | - Bipin Chandra
- Department of Cardiovascular Surgery, Sanjay Gandhi PGIMS, Lucknow, India
| | - Pravin K Goel
- Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India
| |
Collapse
|
30
|
|
31
|
Fox AA, Nascimben L, Body SC, Collard CD, Mitani AA, Liu KY, Muehlschlegel JD, Shernan SK, Marcantonio ER. Increased perioperative b-type natriuretic peptide associates with heart failure hospitalization or heart failure death after coronary artery bypass graft surgery. Anesthesiology 2013; 119:284-94. [PMID: 23695172 PMCID: PMC3840806 DOI: 10.1097/aln.0b013e318299969c] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart failure (HF) is a leading cause of hospitalization and mortality. Plasma B-type natriuretic peptide (BNP) is an established diagnostic and prognostic ambulatory HF biomarker. We hypothesized that increased perioperative BNP independently associates with HF hospitalization or HF death up to 5 yr after coronary artery bypass graft surgery. METHODS The authors conducted a two-institution, prospective, observational study of 1,025 subjects (mean age = 64 ± 10 yr SD) undergoing isolated primary coronary artery bypass graft surgery with cardiopulmonary bypass. Plasma BNP was measured preoperatively and on postoperative days 1-5. The study outcome was hospitalization or death from HF, with HF events confirmed by reviewing hospital and death records. Cox proportional hazards analyses were performed with multivariable adjustments for clinical risk factors. Preoperative and peak postoperative BNP were added to the multivariable clinical model in order to assess additional predictive benefit. RESULTS One hundred five subjects experienced an HF event (median time to first event = 1.1 yr). Median follow-up for subjects who did not have an HF event = 4.2 yr. When individually added to the multivariable clinical model, higher preoperative and peak postoperative BNP concentrations each, independently associated with the HF outcome (log10 preoperative BNP hazard ratio = 1.93; 95% CI, 1.30-2.88; P = 0.001; log10 peak postoperative BNP hazard ratio = 3.38; 95% CI, 1.45-7.65; P = 0.003). CONCLUSIONS Increased perioperative BNP concentrations independently associate with HF hospitalization or HF death during the 5 yr after primary coronary artery bypass graft surgery. Clinical trials may be warranted to assess whether medical management focused on reducing preoperative and longitudinal postoperative BNP concentrations associates with decreased HF after coronary artery bypass graft surgery.
Collapse
Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Mannacio V, Antignano A, De Amicis V, Di Tommaso L, Giordano R, Iannelli G, Vosa C. B-type natriuretic peptide as a biochemical marker of left ventricular diastolic function: assessment in asymptomatic patients 1 year after valve replacement for aortic stenosis. Interact Cardiovasc Thorac Surg 2013; 17:371-7. [PMID: 23656924 DOI: 10.1093/icvts/ivt186] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Left ventricular (LV) diastolic dysfunction after aortic valve replacement (AVR) carries a substantial risk of development of heart failure and reduced survival. In addition to echocardiography, B-type natriuretic peptide (BNP) provides a powerful incremental assessment of diastolic function. This study evaluates BNP as a marker of LV diastolic dysfunction in a cohort of patients with preserved LV ejection fraction who underwent AVR for pure aortic stenosis and the relationship between BNP values and the grade of LV diastolic dysfunction. METHODS A total of 113 patients were included in the study. Echocardiographic evaluation was performed preoperatively, 5 days postoperatively and at 12-month follow-up, to assess LV dimensional and functional parameters. Diastolic function was labelled as normal, mild, moderate or severe dysfunction. Concomitantly, BNP levels were evaluated. RESULTS Mild to severe diastolic dysfunction occurred preoperatively in all patients. At 12-month follow-up, 65 (62.5%) patients had mild and 25 (24.1%) moderate to severe diastolic dysfunction. BNP values, categorized for quartile distribution, correlated with diastolic dysfunction grade (P<0.001 for each comparison). At receiver operating characteristic analysis, the BNP level of 120 pg/ml was 91% sensitive and 85% specific for diastolic disease, while 300 pg/ml was 80% sensitive and 91% specific for moderate or severe diastolic dysfunction. Twelve months after AVR, BNP values were strongly correlated with the significant echocardiographic parameters suggestive of diastolic dysfunction (P≤0.006 in all cases). CONCLUSIONS The BNP level following AVR is related to diastolic disease severity and may complement echocardiographic evaluation when symptoms are unclear and LV function is difficult to interpret.
Collapse
Affiliation(s)
- Vito Mannacio
- Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
| | | | | | | | | | | | | |
Collapse
|
33
|
Cuthbertson B, Croal B, Rae D, Harrild K, Gibson P, Prescott G, Kengne A, Hillis G. N-terminal pro-B-type natriuretic peptide concentrations and long-term outcome after cardiac surgery: a prospective cohort study. Br J Anaesth 2013. [DOI: 10.1093/bja/aes379] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
34
|
Lara TM, Hajjar LA, de Almeida JP, Fukushima JT, Barbas CSV, Rodrigues ARB, Nozawa E, Feltrim MIZ, Almeida E, Coimbra V, Osawa E, Ianotti RDM, Leme AC, Jatene FB, Auler JOC, Galas FRBG. High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery. Clinics (Sao Paulo) 2013; 68:33-8. [PMID: 23420154 PMCID: PMC3552447 DOI: 10.6061/clinics/2013(01)oa05] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 09/04/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period.
Collapse
Affiliation(s)
- Thiago Martins Lara
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Heart Institute (InCor), Surgical Intensive Care Unit and Department of Anesthesiology, São Paulo/SP, Brazil.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Holm J, Vidlund M, Vanky F, Friberg O, Håkanson E, Svedjeholm R. Preoperative NT-proBNP independently predicts outcome in patients with acute coronary syndrome undergoing CABG. SCAND CARDIOVASC J 2012; 47:28-35. [PMID: 22989031 DOI: 10.3109/14017431.2012.731518] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The predictive value of preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated in patients with acute coronary syndrome undergoing coronary artery bypass grafting (CABG). DESIGN As a substudy to a clinical trial 383 patients with acute coronary syndrome undergoing CABG were studied. 17 patients had a concomitant procedure. NT-proBNP was measured immediately preoperatively and evaluated with regard to in-hospital mortality, and severe circulatory failure postoperatively according to prespecified criteria. Follow-up was 3.2 ± 0.9 years. RESULTS In patients with isolated CABG, receiver operating characteristics (ROC) analysis showed an area under the curve (AUC) of 0.82 for in-hospital mortality and 0.87 for severe circulatory failure respectively with a best cut-off for preoperative NT-proBNP of 1028 ng/L. This cut-off level independently predicted severe circulatory failure. Patients with NT-proBNP < 1028 ng/L had significantly better long-term survival (p = 0.004). Preoperative NT-proBNP was higher in patients with concomitant procedure than isolated CABG (2146 ± 1858 v 887 ± 1635 ng/L; p = 0.0005). In patients with concomitant procedure ROC analysis showed an AUC of 0.93 for severe circulatory failure with a best cut-off for preoperative NT-proBNP of 3145 ng/L. CONCLUSIONS Preoperative NT-proBNP predicted in-hospital mortality, severe circulatory failure postoperatively and long-term survival in patients undergoing surgery for acute coronary syndrome but a higher threshold was found in patients having concomitant procedures.
Collapse
Affiliation(s)
- Jonas Holm
- Division of Cardiovascular Medicine, Department of Cardiothoracic Surgery and Cardiothoracic Anesthesia, Linköping University Hospital, Linköping University, Linköping, Sweden.
| | | | | | | | | | | |
Collapse
|
36
|
Fellahi JL, Daccache G, Makroum Y, Massetti M, Gérard JL, Hanouz JL. The Prognostic Value of B-Type Natriuretic Peptide After Cardiac Surgery: A Comparative Study Between Coronary Artery Bypass Graft Surgery and Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2012; 26:624-30. [DOI: 10.1053/j.jvca.2011.07.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Indexed: 11/11/2022]
|
37
|
Foroughi M, Rahimian H, Dabbagh A, Majidi M, Hekmat M, Beheshti M, Shahzamani M. Postoperative N-terminal Pro–Brain Natriuretic Peptide Level in Coronary Artery Bypass Surgery With Ventricular Dysfunction After Perioperative Glucose-Insulin-Potassium Treatment. J Cardiothorac Vasc Anesth 2012; 26:631-6. [DOI: 10.1053/j.jvca.2011.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Indexed: 01/09/2023]
|
38
|
Fox AA, Body SC. Assessment of preoperative B-type natriuretic peptide in adult surgeries: is it useful? Anesth Analg 2012; 112:1005-7. [PMID: 21515646 DOI: 10.1213/ane.0b013e318210c739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
39
|
Stahl GL, Shernan SK, Smith PK, Levy JH. Complement activation and cardiac surgery: a novel target for improving outcomes. Anesth Analg 2012; 115:759-71. [PMID: 22798530 DOI: 10.1213/ane.0b013e3182652b7d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Complement activation and the resulting inflammatory response is an important potential mechanism for multisystem organ injury in cardiac surgery. Novel therapeutic strategies using complement inhibitors may hold promise for improving outcomes for cardiac surgical patients by attenuating complement activation or its biologically active effector molecules. Recent clinical trials evaluating complement inhibitors have provided important data to further delineate the impact of complement activation and its inhibition on clinical outcomes. In this review we examine the role of complement activation and its inhibition as a therapeutic approach in cardiac surgery.
Collapse
Affiliation(s)
- Gregory L Stahl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | | | | | | |
Collapse
|
40
|
Augoustides JG. Serum creatinine as a perioperative biomarker: A challenge for perioperative management and an opportunity for the Cardiothoracic Surgery Trials Network. J Thorac Cardiovasc Surg 2012; 143:523-4. [DOI: 10.1016/j.jtcvs.2011.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 11/09/2011] [Accepted: 12/14/2011] [Indexed: 11/30/2022]
|
41
|
Mercantini P, Di Somma S, Magrini L, Kazemi Nava A, Scarinci A, La Torre M, Ferri M, Ferri E, Petrucciani N, Ziparo V. Preoperative Brain Natriuretic Peptide (BNP) Is a Better Predictor of Adverse Cardiac Events Compared to Preoperative Scoring System in Patients Who Underwent Abdominal Surgery. World J Surg 2011; 36:24-30. [DOI: 10.1007/s00268-011-1354-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
42
|
Kim YK, Shin WJ, Song JG, Kim Y, Kim WJ, Kim SH, Hwang GS. Evaluation of intraoperative brain natriuretic peptide as a predictor of 1-year mortality after liver transplantation. Transplant Proc 2011; 43:1684-90. [PMID: 21693258 DOI: 10.1016/j.transproceed.2011.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 02/02/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although brain natriuretic peptide (BNP), a marker of cardiac dysfunction, has been known to predict postoperative mortality, little is known about the postoperative prognostic ability of BNP in liver transplantation (OLT) recipients. We aimed to determine whether intraoperative BNP level can predict 1-year all-cause mortality after OLT. METHODS We retrospectively investigated 525 OLT recipients. BNP and hemodynamic parameters were simultaneously measured 1 hour after induction of anesthesia. Cox regression analysis and receiver operating characteristic curve analysis were performed to determine clinical predictors and optimal cutoff values of post-OLT mortality. RESULTS The 1-year all-cause mortality rate was 9.7% (51/525). Median BNP concentration was significantly higher in nonsurvivors than in survivors (114 vs 56 pg/mL, P < .001). Significant factors in univariate Cox regression analysis were Child-Pugh score, model for end-stage liver disease (MELD) score, logBNP, hemoglobin, creatinine, heart rate, systolic pulmonary arterial pressure, and central venous pressure. In multivariate Cox regression analysis, independent predictors of posttransplant mortality were MELD score and logBNP. However, simultaneously measured hemodynamic parameters did not remain predictors. BNP levels greater than a cutoff of 136 pg/mL (specificity = 83.5%, negative predictive value = 93.6%) were associated with increased post-OLT mortality (log-rank test P < .001). CONCLUSIONS Intraoperative BNP level is an independent predictor of 1-year all-cause mortality after OLT with a high negative predictive value, suggesting that its measurement appears useful in identifying patients at low risk of post-OLT mortality.
Collapse
Affiliation(s)
- Y K Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | | | | | | | | | | |
Collapse
|
43
|
Fox AA, Pretorius M, Liu KY, Collard CD, Perry TE, Shernan SK, De Jager PL, Hafler DA, Herman DS, DePalma SR, Roden DM, Muehlschlegel JD, Donahue BS, Darbar D, Seidman JG, Body SC, Seidman CE. Genome-wide assessment for genetic variants associated with ventricular dysfunction after primary coronary artery bypass graft surgery. PLoS One 2011; 6:e24593. [PMID: 21980348 PMCID: PMC3184087 DOI: 10.1371/journal.pone.0024593] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 08/14/2011] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative ventricular dysfunction (VnD) occurs in 9–20% of coronary artery bypass graft (CABG) surgical patients and is associated with increased postoperative morbidity and mortality. Understanding genetic causes of postoperative VnD should enhance patient risk stratification and improve treatment and prevention strategies. We aimed to determine if genetic variants associate with occurrence of in-hospital VnD after CABG surgery. Methods A genome-wide association study identified single nucleotide polymorphisms (SNPs) associated with postoperative VnD in male subjects of European ancestry undergoing isolated primary CABG surgery with cardiopulmonary bypass. VnD was defined as the need for ≥2 inotropes or mechanical ventricular support after CABG surgery. Validated SNPs were assessed further in two replication CABG cohorts and meta-analysis was performed. Results Over 100 SNPs were associated with VnD (P<10−4), with one SNP (rs17691914) encoded at 3p22.3 reaching genome-wide significance (Padditive model = 2.14×10−8). Meta-analysis of validation and replication study data for 17 SNPs identified three SNPs associated with increased risk for developing postoperative VnD after adjusting for clinical risk factors. These SNPs are located at 3p22.3 (rs17691914, ORadditive model = 2.01, P = 0.0002), 3p14.2 (rs17061085, ORadditive model = 1.70, P = 0.0001) and 11q23.2 (rs12279572, ORrecessive model = 2.19, P = 0.001). Conclusions No SNPs were consistently associated with strong risk (ORadditive model>2.1) of developing in-hospital VnD after CABG surgery. However, three genetic loci identified by meta-analysis were more modestly associated with development of postoperative VnD. Studies of larger cohorts to assess these loci as well as to define other genetic mechanisms and related biology that link genetic variants to postoperative ventricular dysfunction are warranted.
Collapse
Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Lurati Buse GA, Koller MT, Burkhart C, Seeberger MD, Filipovic M. The Predictive Value of Preoperative Natriuretic Peptide Concentrations in Adults Undergoing Surgery. Anesth Analg 2011; 112:1019-33. [DOI: 10.1213/ane.0b013e31820f286f] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
45
|
Fellahi JL, Piriou V, Longrois D. [Cardiac biomarkers in perioperative risk stratification]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:126-140. [PMID: 21282034 DOI: 10.1016/j.annfar.2010.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Accepted: 11/25/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES The field of new cardiac biomarkers has triggered physicians' enthusiasm because of their potential diagnostic and prognostic values for routine clinical practice in the surgical setting. The objective of the present article is to review the role of new cardiac biomarkers and their potential additive clinical value in predicting short- and long-term risk following cardiac and non-cardiac surgery. DATA SOURCES A PubMed(®) database research in English and French languages published until June 2010. Keywords were cardiac biomarkers, troponins, cardiac troponin I (cTnI), natriuretic peptides, B-type natriuretic peptide (BNP), C-reactive protein (CRP), multiple markers approach, risk stratification, clinical risk scores. DATA SYNTHESIS Numerous publications deal with the diagnostic and prognostic values of new cardiac biomarkers in cardiac and non-cardiac surgical settings and provide an increasing evidence of their interest, validating different hierarchical steps which are mandatory before recommending a wide use of biomarkers for routine practice. Even if the first studies demonstrating an additional prognostic value of serum postoperative cTnI and/or preoperative BNP when compared with clinical predictive models are now available, we still lack data concerning an actual positive impact of new biomarkers measurements on clinical decision making or practice, as well as patient care and outcome. CONCLUSIONS While use of new cardiac biomarkers in the perioperative period appears to be a simple and objective tool for risk stratification at the bedside, we still need to remain cautious concerning their additional clinical value on existing predictive models for routine practice.
Collapse
Affiliation(s)
- J-L Fellahi
- Pôle anesthésie-réanimation-Samu-hémovigilance-coordination hospitalière, CHU de Caen, UFR de médecine, université de Caen-Basse Normandie, avenue de la Côte-de-Nacre, Caen cedex 9, France.
| | | | | |
Collapse
|
46
|
Fellahi JL, Daccache G, Rubes D, Massetti M, Gérard JL, Hanouz JL. Does preoperative B-type natriuretic peptide better predict adverse outcome and prolonged length of stay than the standard European System for Cardiac Operative Risk Evaluation after cardiac surgery? J Cardiothorac Vasc Anesth 2010; 25:256-62. [PMID: 20674395 DOI: 10.1053/j.jvca.2010.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although B-type natriuretic peptide (BNP) strongly predicts cardiac morbidity and mortality, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) has a modest predictive value to identify a composite operative risk after cardiac surgery. The authors tested the hypothesis that a single preoperative BNP measurement would be superior to standard EuroSCORE in predicting composite adverse outcomes after cardiac surgery. DESIGN A prospective observational study. SETTING A teaching university hospital. PARTICIPANTS Two hundred eight adult patients. INTERVENTIONS Conventional cardiac surgery with cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS The preoperative additive EuroSCORE and BNP measurement were performed in all patients. Postoperative nonfatal major adverse cardiac events (malignant ventricular arrhythmia, myocardial infarction, and cardiac dysfunction), all-cause mortality, and prolonged lengths of stay were chosen as study endpoints. Predictive abilities of both EuroSCORE and BNP were assessed using logistic regression and compared with receiver operating characteristic (ROC) curves. Thirty-six (17%, 95% confidence interval [CI], 12%-22%) patients experienced 49 events over the study period. The areas under the ROC curves assessing the utility of EuroSCORE and BNP in predicting adverse outcome and prolonged in-hospital stay were 0.59 (95% CI, 0.48-0.69) versus 0.76 (95% CI, 0.68-0.85; p < 0.001) and 0.65 (95% CI, 0.57-0.74) versus 0.71 (95% CI, 0.63-0.80; p = 0.147), respectively. Using logistic regression, BNP considered as a dichotomized variable was the only independent predictor of adverse cardiac outcome (adjusted odds ratio = 10.7; 95% CI, 4.1-27.8; p < 0.001). CONCLUSIONS Preoperative BNP measurement is a strong, independent, and more accurate predictor of adverse outcome than EuroSCORE in patients undergoing cardiac surgery. BNP could be considered as a simple and objective tool for the detection of high-risk patients after cardiac surgery.
Collapse
Affiliation(s)
- Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, CHU Côte de Nacre, University of Caen Basse-Normandie, Caen, France.
| | | | | | | | | | | |
Collapse
|
47
|
Muehlschlegel JD, Perry TE, Liu KY, Fox AA, Collard CD, Shernan SK, Body SC. Heart-type fatty acid binding protein is an independent predictor of death and ventricular dysfunction after coronary artery bypass graft surgery. Anesth Analg 2010; 111:1101-9. [PMID: 20457766 DOI: 10.1213/ane.0b013e3181dd9516] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart-type fatty acid binding protein (hFABP) functions as a myocardial fatty acid transporter and is released into the circulation early after myocardial injury. We hypothesized that hFABP is superior to conventional cardiac biomarkers for predicting early perioperative myocardial injury after coronary artery bypass graft (CABG) surgery. METHODS A prospective cohort study of 1298 patients undergoing primary CABG with cardiopulmonary bypass (CPB) was performed at 2 institutions. Four plasma myocardial injury biomarkers (hFABP; cardiac troponin I [cTnI]; creatine kinase, MB [CK-MB] fraction; and myoglobin) were measured at 7 perioperative time points. The association among perioperative cardiac biomarkers and ventricular dysfunction, hospital length of stay (HLOS), and up to 5-year postoperative mortality (median 3.3 years) was assessed using Cox proportional hazard models. We defined in-hospital ventricular dysfunction as a new requirement for 2 or more inotropes, or new placement of an intraaortic balloon pump, or ventricular assist device either during the intraoperative period after the patient separated from CPB or postoperatively in the intensive care unit. RESULTS The positive and negative predictive values of mortality for hFABP are 13% (95% confidence interval [CI], 9%-19%) and 95% (95% CI, 94%-96%), respectively, which is higher than for cTnI and CK-MB. After adjusting for clinical predictors, both postoperative day (POD) 1 and peak hFABP levels were independent predictors of ventricular dysfunction (P < 0.0001), HLOS (P < 0.05), and 5-year mortality (P < 0.0001) after CABG surgery. Furthermore, POD1 and peak hFABP levels were significantly superior to other evaluated biomarkers for predicting mortality. In a repeated-measures analysis, hFABP outperformed all other models of fit for HLOS. Patients with POD2 hFABP levels higher than post-CPB hFABP levels had an increased mortality compared with those patients whose POD2 hFABP levels decreased from their post-CPB level (hazard ratio, 10.9; 95% CI, 5.0-23.7; P = 7.2 × 10(-10)). Mortality in the 120 patients (10%) with a later hFABP peak was 18.3%, compared with 4.7% in those who did not peak later. Alternatively, for cTnI or CK-MB, no difference in mortality was detected. CONCLUSION Compared with traditional markers of myocardial injury after CABG surgery, hFABP peaks earlier and is a superior independent predictor of postoperative mortality and ventricular dysfunction.
Collapse
Affiliation(s)
- Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
| | | | | | | | | | | | | |
Collapse
|
48
|
Comparison of the utility of preoperative versus postoperative B-type natriuretic peptide for predicting hospital length of stay and mortality after primary coronary artery bypass grafting. Anesthesiology 2010; 112:842-51. [PMID: 20216395 DOI: 10.1097/aln.0b013e3181d23168] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Preoperative B-type natriuretic peptide (BNP) is known to predict adverse outcomes after cardiac surgery. The value of postoperative BNP for predicting adverse outcomes is less well delineated. The authors hypothesized that peak postoperative plasma BNP (measured postoperative days 1-5) predicts hospital length of stay (HLOS) and mortality in patients undergoing primary coronary artery bypass grafting, even after adjusting for preoperative BNP and perioperative clinical risk factors. METHODS This study is a prospective longitudinal study of 1,183 patients undergoing primary coronary artery bypass grafting surgery. Mortality was defined as all-cause death within 5 yr after surgery. Cox proportional hazards analyses were conducted to separately evaluate the associations between peak postoperative BNP and HLOS and mortality. Multivariable adjustments were made for patient demographics, preoperative BNP concentration, and clinical risk factors. BNP measurements were log10 transformed before analysis. RESULTS One hundred fifteen deaths (9.7%) occurred in the cohort (mean follow-up = 4.3 yr, range = 2.38-5.0 yr). After multivariable adjustment for preoperative BNP and clinical covariates, peak postoperative BNP predicted HLOS (hazard ratio [HR] = 1.28, 95% CI = 1.002-1.64, P = 0.049) but not mortality (HR = 1.62, CI = 0.71-3.68, P = 0.25), whereas preoperative BNP independently predicted HLOS (HR = 1.09, CI = 1.01-1.18, P = 0.03) and approached being an independent predictor of mortality (HR = 1.36, CI = 0.96-1.94, P = 0.08). When preoperative and peak postoperative BNP were separately adjusted for within the clinical multivariable models, each independently predicted HLOS (preoperative BNP HR = 1.13, CI = 1.05-1.21, P = 0.0007; peak postoperative BNP HR = 1.44, CI = 1.15-1.81, P = 0.001) and mortality (preoperative BNP HR = 1.50, CI = 1.09-2.07, P = 0.01; peak postoperative BNP HR = 2.29, CI = 1.11-4.73, P = 0.02). CONCLUSIONS Preoperative BNP may be better than peak postoperative BNP for predicting HLOS and longer term mortality after primary coronary artery bypass grafting surgery.
Collapse
|
49
|
Does B-type natriuretic peptide or its gene polymorphism predict patient outcome after coronary artery bypass graft surgery? Anesthesiology 2009; 111:1378-9; author reply 1378-9. [PMID: 19934885 DOI: 10.1097/aln.0b013e3181bf2fc9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
50
|
Natriuretic peptide system gene variants are associated with ventricular dysfunction after coronary artery bypass grafting. Anesthesiology 2009; 110:738-47. [PMID: 19326473 DOI: 10.1097/aln.0b013e31819c7496] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Ventricular dysfunction (VnD) after primary coronary artery bypass grafting is associated with increased hospital stay and mortality. Natriuretic peptides have compensatory vasodilatory, natriuretic, and paracrine influences on myocardial failure and ischemia. The authors hypothesized that natriuretic peptide system gene variants independently predict risk of VnD after primary coronary artery bypass grafting. METHODS A total of 1,164 patients undergoing primary coronary artery bypass grafting with cardiopulmonary bypass at two institutions were prospectively enrolled. After prospectively defined exclusions, 697 patients of European descent (76 with VnD) were analyzed. VnD was defined as need for at least 2 new inotropes and/or new mechanical ventricular support after coronary artery bypass grafting. A total of 139 haplotype-tagging single nucleotide polymorphisms (SNPs) within 7 genes (NPPA, NPPB, NPPC, NPR1, NPR2, NPR3, CORIN) were genotyped. SNPs univariately associated with VnD were entered into logistic regression models adjusting for clinical covariates predictive of VnD. To control for multiple comparisons, permutation analyses were conducted for all SNP associations. RESULTS After adjusting for clinical covariates and multiple comparisons within each gene, seven NPPA/NPPB SNPs (rs632793, rs6668352, rs549596, rs198388, rs198389, rs6676300, rs1009592) were associated with decreased risk of postoperative VnD (additive model; odds ratios 0.44-0.55; P = 0.010- 0.036) and four NPR3 SNPs (rs700923, rs16890196, rs765199, rs700926) were associated with increased risk of postoperative VnD (recessive model; odds ratios 3.89-4.28; P = 0.007-0.034). CONCLUSIONS Genetic variation within the NPPA/NPPB and NPR3 genes is associated with risk of VnD after primary coronary artery bypass grafting. Knowledge of such genotypic predictors may result in better understanding of the molecular mechanisms underlying postoperative VnD.
Collapse
|