There are limited data on the effect of baseline B-type natriuretic peptide (BNP) on the outcome after transcatheter aortic valve implantation (TAVI). We investigated the influence of baseline BNP levels on the short-term and midterm clinical outcomes after TAVI. During a 3-year period, 780 patients with severe aortic stenosis underwent TAVI at our institute and had baseline BNP levels. We compared the high, mid, and low tertiles of BNP levels. TAVI end points, device success, and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. Device success was significantly lower for patients with high BNP (98.1% vs 96.2% vs 91.9% for the low, mid, and high BNP tertiles, respectively; p = 0.003). All-cause mortality up to 30 days was 1.2% (3 of 260) versus 2.3% (6 of 260) versus 5% (13 of 260), respectively (p = 0.03). Six-month mortality rate was 4.1% (10 of 241) for the low BNP tertile, 5% (12 of 239) for the mid BNP tertile, and 17.1% (40 of 234) for the high BNP tertile (p <0.001). In the multivariate model, high tertile of baseline BNP was found to be significantly associated with all-cause mortality (hazard ratio 3.3, 95% confidence interval 1.64 to 6.48; p = 0.001). In conclusion, elevated BNP levels are associated with increased short-term and midterm mortality after TAVI. We recommend measurement of baseline BNP as part of risk stratification models for TAVI.
B-type natriuretic peptide (BNP) is released from the heart in response to pressure and/or volume overload and has important prognostic value in multiple cardiovascular diseases. In patients with aortic stenosis (AS), BNP levels are associated with severity of the disease and predict development of symptoms. Moreover, BNP was found to predict survival in patients who underwent surgical aortic valve replacement. There are limited data on the effect of baseline BNP or pro-BNP on the clinical outcome after transcatheter aortic valve implantation (TAVI). A recent meta-analysis have found high baseline pro-BNP levels to be strongly associated with 30-day and 1-year mortality after TAVI. Nonetheless, in a substudy of the Placement of Aortic Transcatheter Valves (PARTNER) I trial, baseline BNP was not significant in a multivariate model of 1-year mortality. The present study assesses the influence of baseline BNP levels on the short-term and midterm outcomes after TAVI.
Methods
We examined consecutive patients with severe symptomatic AS who underwent TAVI during a 3-year period at our institute. All patients had congestive heart failure with New-York Heart Association class II to IV symptoms. All underwent preprocedural coronary angiography to assess the need of revascularization. Aortic valve disease was assessed initially with transthoracic echocardiography followed by an electrocardiography-gated, multislice computed tomography angiography study. Sizing for TAVI was made at the operator’s discretion, using data from all available imaging modalities at the time of the procedure including immediate preprocedural 3-dimensional transesophageal echocardiography. Vascular access approach was chosen on the basis of the individual patient’s risk profile. All patients were considered high risk for valve surgery by our institutional heart team. Baseline clinical, echocardiographic, and procedural details for TAVI were recorded for all patients including 1-month clinical and echocardiographic assessments during a follow-up visit. Venous blood samples were drawn from antecubital vein into chilled ethylenediaminetetraacetic (EDTA) acid tubes at the time of admission before TAVI. Serum BNP level was determined using a chemiluminescent immunoassay (ADVIA Centaur BNP, Siemens Healthcare Diagnostics, Tarrytown, New York). Patients were divided into the following BNP tertiles: low BNP 0 to 189 pg/ml (n = 260), mid BNP 190 to 452 pg/ml (n = 260), and high BNP ≥453 pg/ml (n = 260). TAVI end points, device success, and adverse events were considered according to the Valve Academic Research Consortium 2 definitions. A locally appointed institutional review board approved the research protocol, and informed consent was obtained from all subjects.
Continuous variables are expressed as mean ± standard deviation or median (25% to 75% interquartile range) according to the variable distribution. Categorical variables are expressed as number (percentage) of patients in each group. Differences between groups were assessed using the Kruskal–Wallis test or the Student t test for continuous variables and Pearson chi-square test for categorical variables. Kaplan–Meier survival plot significance was estimated using the log-rank test. Cox multivariable regression analysis was performed to identify independent correlates for overall mortality. The multivariate model was built by selecting baseline and procedural variables that satisfied the entry criterion of p <0.05 in a univariate analysis. All the analyses were considered significant at a 2-tailed p value of <0.05. The SPSS statistical package, version 20.0, was used to perform all statistical evaluation (SSPS Inc., Chicago, Illinois).
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