1
|
Hecht S, Giuliani C, Nuche J, Farjat Pasos JI, Bernard J, Tastet L, Abu-Alhayja'a R, Beaudoin J, Côté N, DeLarochellière R, Paradis JM, Clavel MA, Arsenault BJ, Rodés-Cabau J, Pibarot P. Multimarker Approach to Improve Risk Stratification of Patients Undergoing Transcatheter Aortic Valve Implantation. JACC. ADVANCES 2024; 3:100761. [PMID: 38939373 PMCID: PMC11198363 DOI: 10.1016/j.jacadv.2023.100761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 06/29/2024]
Abstract
Background A blood multimarker approach may be useful to enhance risk stratification in patients undergoing TAVI. Objectives The objective of this study was to determine the prognostic value of multiple blood biomarkers in transcatheter aortic valve implantation (TAVI) patients. Methods In this prospective study, several blood biomarkers of cardiovascular function, inflammation, and renal function were measured in 362 patients who underwent TAVI. The cohort was divided into 3 groups according to the number of elevated blood biomarkers (ie, ≥ median value for the whole cohort) for each patient before the procedure. Survival analyses were conducted to evaluate the association between blood biomarkers and risk of adverse event following TAVI. Results During a median follow-up of 2.5 (IQR: 1.9-3.2) years, 34 (9.4%) patients were rehospitalized for heart failure, 99 (27%) patients died, and 113 (31.2%) met the composite endpoint of all-cause mortality or heart failure rehospitalization. Compared to patients with 0 to 3 elevated biomarkers (referent group), those with 4 to 7 and 8 to 9 elevated biomarkers had a higher risk of all-cause mortality (HR: 1.54 [95% CI: 0.84-2.80], P = 0.16, and HR: 2.81 [95% CI: 1.53-5.15], P < 0.001, respectively) and of the composite endpoint (HR: 1.65 [95% CI: 0.95-2.84], P = 0.07, and HR: 2.67 [95% CI: 1.52-4.70] P < 0.001, respectively). Moreover, adding the number of elevated blood biomarkers into the clinical multivariable model provided significant incremental predictive value for all-cause mortality (Net Reclassification Index = 0.71, P < 0.001). Conclusions An increasing number of elevated blood biomarkers is associated with higher risks of adverse clinical outcomes following TAVI. The blood multimarker approach may be helpful to enhance risk stratification in TAVI patients.
Collapse
Affiliation(s)
- Sébastien Hecht
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Carlos Giuliani
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Jorge Nuche
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Julio I. Farjat Pasos
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Jérémy Bernard
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Lionel Tastet
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Rami Abu-Alhayja'a
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Jonathan Beaudoin
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Nancy Côté
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Robert DeLarochellière
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Jean-Michel Paradis
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Benoit J. Arsenault
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| | - Philippe Pibarot
- Department of Cardiology, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Québec, Canada
- Faculté de médecine, Université Laval, Québec, Canada
| |
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
|
Shah SM, Shah J, Lakey SM, Garg P, Ripley DP. Pathophysiology, emerging techniques for the assessment and novel treatment of aortic stenosis. Open Heart 2023; 10:e002244. [PMID: 36963766 PMCID: PMC10040005 DOI: 10.1136/openhrt-2022-002244] [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: 12/23/2022] [Accepted: 03/09/2023] [Indexed: 03/26/2023] Open
Abstract
Our perspectives on aortic stenosis (AS) are changing. Evolving from the traditional thought of a passive degenerative disease, developing a greater understanding of the condition's mechanistic underpinning has shifted the paradigm to an active disease process. This advancement from the 'wear and tear' model is a result of the growing economic and health burden of AS, particularly within industrialised countries, prompting further research. The pathophysiology of calcific AS (CAS) is complex, yet can be characterised similarly to that of atherosclerosis. Progressive remodelling involves lipid-protein complexes, with lipoprotein(a) being of particular interest for diagnostics and potential future treatment options.There is an unmet clinical need for asymptomatic patient management; no pharmacotherapies are proven to slow progression and intervention timing varies. Novel approaches are developing to address this through: (1) screening with circulating biomarkers; (2) development of drugs to slow disease progression and (3) early valve intervention guided by medical imaging. Existing biomarkers (troponin and brain natriuretic peptide) are non-specific, but cost-effective predictors of ventricular dysfunction. In addition, their integration with cardiovascular MRI can provide accurate risk stratification, aiding aortic valve replacement decision making. Currently, invasive intervention is the only treatment for AS. In comparison, the development of lipoprotein(a) lowering therapies could provide an alternative; slowing progression of CAS, preventing left ventricular dysfunction and reducing reliance on surgical intervention.The landscape of AS management is rapidly evolving. This review outlines current understanding of the pathophysiology of AS, its management and future perspectives for the condition's assessment and treatment.
Collapse
Affiliation(s)
- Syed Muneeb Shah
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Jay Shah
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
| | - Samuel Mark Lakey
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Pankaj Garg
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Department of Cardiology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - David Paul Ripley
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sunderland, UK
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| |
Collapse
|
4
|
Pavlides GS, Chatzizisis YS, Porter TR. Integrating hemodynamics with ventricular and valvular remodeling in aortic stenosis. A paradigm shift in therapeutic decision making. Am Heart J 2022; 254:66-76. [PMID: 35970400 DOI: 10.1016/j.ahj.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/05/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
Aortic valve stenosis (AS) has traditionally been approached in hemodynamic terms. Although hemodynamics and symptoms have formed the basis of recommending interventional treatment in AS, other factors reflecting left ventricular and valvular and/or vascular remodeling are equally important for the prognosis and outcome of patients with AS. Left ventricular and valvular/vascular remodeling in AS do not consistently correlate with hemodynamic severity of AS. Those remodeling changes are reflected and can be detected by a variety of novel laboratory and imaging techniques, including biomarkers, echocardiography, cardiac magnetic resonance and gated Computer Tomography (CT) imaging. Taking all those elements into Heart Team therapeutic decision making in patients with AS, can significantly improve appropriate patient selection for interventional treatment and patient outcomes. We review this novel approach and propose a simple algorithm for decision making by the Heart Team, in patients with moderate or severe AS.
Collapse
|
5
|
Evaluation of new and old biomarkers in dogs with degenerative mitral valve disease. BMC Vet Res 2022; 18:256. [PMID: 35780161 PMCID: PMC9250216 DOI: 10.1186/s12917-022-03343-z] [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: 03/23/2022] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dogs with degenerative mitral valve disease are commonly presented to small animal clinicians. Diagnosis, clinical staging, and therapeutic design are based on a combination of clinical examination, radiography, and echocardiography. To support diagnosis and clinical monitoring, a multi-marker-based approach would be conceivable. The aim of this study was to investigate the suitability of Galectin-3 and interleukin-1 receptor-like 1 protein (ST2) in dogs with degenerative mitral valve disease in accordance with N-terminal-prohormone-B-type natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI). For this purpose, serum concentrations of Galectin-3 and ST2 of 64 dogs with different stages of mitral valve disease and 21 dogs without cardiac disease were analyzed at the first examination and six months later. Echocardiography, blood cell count and clinical chemistry were performed and established biomarkers NT-proBNP and cTnI were measured additionally. Differences in the biomarker concentrations between all groups at both timepoints and the change in biomarker concentrations from first to second evaluation was investigated. Furthermore, correlations of each biomarker, between biomarkers and echocardiographic measurements, were calculated. Finally, the receiver-operating characteristic curve and the area under the curve analysis were performed to differentiate between disease stages and controls. Results Serum concentrations of Galectin-3 and ST2 were not statistically different between canine patients in the respective stages of mitral valve disease or in comparison to dogs in the control group at any timepoint. A significant increase in ST2 concentrations from the baseline to the follow-up examination was observed in dogs classified as stage B1 and the control group. The concentrations of NT-proBNP and cTnI in stage C dogs were significantly increased in comparison to the other groups. Conclusions In this study, no relation between Galectin-3 and ST2 levels to the presence or stage of mitral valve disease could be detected. Nevertheless, considering the increase in ST2 concentrations from the first to second measurement, its value on monitoring disease progress could be feasible. In agreement with previous studies, NT-proBNP and cTnI have once more proven their utility in assessing disease severity. The approach of examining new cardiac biomarkers in dogs is still worth pursuing.
Collapse
|
6
|
Flachskampf FA, Chandrashekhar Y. "Cardiac Damage" Predicts Prognosis, But Can It Identify Modifiable Prognosis? JACC. CARDIOVASCULAR IMAGING 2022; 15:1170-1173. [PMID: 35680227 DOI: 10.1016/j.jcmg.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
7
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Rafael Sádaba J, Tribouilloy C, Wojakowski W. Guía ESC/EACTS 2021 sobre el diagnóstico y tratamiento de las valvulopatías. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
8
|
Tan ESJ, Oon YY, Chan SP, Liew OW, Chong JPC, Tay E, Soo WM, Yip JWL, Gong L, Lunaria JB, Yong QW, Lee EM, Yeo DPS, Ding ZP, Tang HC, Ewe SH, Chin CCW, Chai SC, Goh PP, Ling LF, Ong HY, Richards AM, Ling LH. Novel predictive role for mid-regional proadrenomedullin in moderate to severe aortic stenosis. Heart 2022; 108:1319-1327. [PMID: 35332049 DOI: 10.1136/heartjnl-2021-320707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/07/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We investigated the prognostic significance of selected known and novel circulating biomarkers in aortic stenosis (AS). METHODS N-terminal pro-BNP (NT-proBNP), high-sensitivity troponin-T (hsTnT), growth differentiation factor-15 (GDF-15), suppression of tumorigenicity-2 (ST2), mid-regional proadrenomedullin (MR-proADM) and mid-regional proatrial natriuretic peptide (MR-proANP) were measured in patients with moderate to severe AS, New York Heart Association (NYHA) class I-II and left ventricular ejection fraction ≥50%, recruited consecutively across five centres from 2011 to 2018. Their ability to predict both primary (all-cause mortality, heart failure hospitalisation or progression to NYHA class III-IV) and secondary (additionally incorporating syncope and acute coronary syndrome) outcomes was determined by competing risk analyses. RESULTS Among 173 patients with AS (age 69±11 years, 55% male, peak transaortic velocity (Vmax) 4.0±0.8 m/s), the primary and secondary outcomes occurred in 59 (34%) and 66 (38%), respectively. With aortic valve replacement as a competing risk, the primary outcome was determined consistently by the comorbidity index and each selected biomarker except ST2 (p<0.05), independent of NYHA class, Vmax, LV-global longitudinal strain and serum creatinine. MR-proADM had the highest discriminative value for both primary (subdistribution HR (SHR) 11.3, 95% CI 3.9 to 32.7) and secondary outcomes (SHR 12.6, 95% CI 4.7 to 33.5). Prognostic assessment of dual-biomarker combinations identified MR-proADM plus either hsTnT or NT-proBNP as the best predictive model for both clinical outcomes. Paired biomarker models were not superior to those including MR-proADM as the sole circulating biomarker. CONCLUSION MR-proADM most powerfully portended worse prognosis and should be further assessed as possibly the biomarker of choice for risk stratification in AS.
Collapse
Affiliation(s)
- Eugene S J Tan
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Yen Yee Oon
- Department of Cardiology, National University Heart Centre, Singapore.,Department of Cardiology, Sarawak Heart Center, Sarawak, Malaysia
| | - Siew Pang Chan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Oi Wah Liew
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre, Singapore
| | - Jenny P C Chong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, Singapore.,Asian Heart & Vascular Centre, Mount Elizabeth Novena Hospital, Singapore
| | - Wern Miin Soo
- Department of Cardiology, National University Heart Centre, Singapore
| | - James W L Yip
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Lingli Gong
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | - Quek Wei Yong
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Evelyn Min Lee
- Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Daniel P S Yeo
- Department of Cardiology, Tan Tock Seng Hospital, Singapore.,Apex Heart Clinic, Gleneagles Hospital, Singapore
| | - Zee Pin Ding
- Department of Cardiology, National Heart Centre, Singapore
| | - Hak Chiaw Tang
- Department of Cardiology, National Heart Centre, Singapore
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre, Singapore
| | | | - Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore
| | - Ping Ping Goh
- Asian Heart & Vascular Centre, Mount Elizabeth Novena Hospital, Singapore
| | - Lee Fong Ling
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore
| | - Hean Yee Ong
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore
| | - A Mark Richards
- Department of Cardiology, National University Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre, Singapore.,Christchurch Heart Institute, University of Otago, Dunedin, New Zealand
| | - Lieng Hsi Ling
- Department of Cardiology, National University Heart Centre, Singapore .,Yong Loo Lin School of Medicine, National University Singapore, Singapore.,Cardiovascular Research Institute, National University Heart Centre, Singapore
| |
Collapse
|
9
|
Stein EJ, Fearon WF, Elmariah S, Kim JB, Kapadia S, Kumbhani DJ, Gillam L, Whisenant B, Quader N, Zajarias A, Welt FG, Bavry AA, Coylewright M, Piana RN, Mallugari RR, Clark DE, Patel JN, Gonzales H, Gupta DK, Vatterott A, Jackson N, Huang S, Lindman BR. Left Ventricular Hypertrophy and Biomarkers of Cardiac Damage and Stress in Aortic Stenosis. J Am Heart Assoc 2022; 11:e023466. [PMID: 35301869 PMCID: PMC9075421 DOI: 10.1161/jaha.121.023466] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Left ventricular hypertrophy (LVH) is associated with increased mortality risk and rehospitalization after transcatheter aortic valve replacement among those with severe aortic stenosis. Whether cardiac troponin (cTnT) and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) risk stratify patients with aortic stenosis and without LVH is unknown. Methods and Results In a multicenter prospective registry of 923 patients with severe aortic stenosis undergoing transcatheter aortic valve replacement, we included 674 with core‐laboratory‐measured LV mass index, cTnT, and NT‐proBNP. LVH was defined by sex‐specific guideline cut‐offs and elevated biomarker levels were based on age and sex cut‐offs. Adjusted Cox proportional hazards models evaluated associations between LVH and biomarkers and all‐cause death out to 5 years. Elevated cTnT and NT‐proBNP were present in 82% and 86% of patients with moderate/severe LVH, respectively, as compared with 66% and 69% of patients with no/mild LVH, respectively (P<0.001 for each). After adjustment, compared with no/mild LVH, moderate/severe LVH was associated with an increased hazard of mortality (adjusted hazard ratio [aHR], 1.34; 95% CI 1.01–1.77, P=0.043). cTnT and NT‐proBNP each risk stratified patients with moderate/severe LVH (P<0.05). In a model with both biomarkers and LVH included, elevated cTnT (aHR, 2.08; 95% CI 1.45–3.00, P<0.001) and elevated NT‐proBNP (aHR, 1.46; 95% CI 1.00–2.11, P=0.049) were each associated with increased mortality risk, whereas moderate/severe LVH was not (P=0.15). Conclusions Elevations in circulating cTnT and NT‐proBNP are more common as LVH becomes more pronounced but are also observed in those with no/minimal LVH. As measures of maladaptive remodeling and cardiac injury, cTnT and NT‐proBNP predict post‐transcatheter aortic valve replacement mortality better than LV mass index. These findings may have important implications for risk stratification and treatment of patients with aortic stenosis.
Collapse
Affiliation(s)
- Elliot J Stein
- Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - William F Fearon
- Division of Cardiology Department of Medicine Stanford Medical Center Palo Alto CA
| | - Sammy Elmariah
- Division of Cardiology Department of Medicine Massachusetts General Hospital Boston MA
| | - Juyong B Kim
- Division of Cardiology Department of Medicine Stanford Medical Center Palo Alto CA
| | - Samir Kapadia
- Division of Cardiology Department of Medicine Cleveland Clinic Foundation Cleveland OH
| | - Dharam J Kumbhani
- Division of Cardiology Department of Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Linda Gillam
- Division of Cardiology Department of Medicine Morristown Medical Center Morristown NJ
| | - Brian Whisenant
- Division of Cardiology Department of Medicine Intermountain Heart Institute Murray UT
| | - Nishath Quader
- Division of Cardiology Department of Medicine Barnes-Jewish Hospital St. Louis MO
| | - Alan Zajarias
- Division of Cardiology Department of Medicine Barnes-Jewish Hospital St. Louis MO
| | - Frederick G Welt
- Division of Cardiology Department of Medicine University of Utah Hospital Salt Lake City UT
| | - Anthony A Bavry
- Division of Cardiology Department of Medicine University of Texas Southwestern Medical Center Dallas TX
| | - Megan Coylewright
- Department of Cardiovascular Medicine The Erlanger Heart and Lung Institute Chattanooga TN
| | - Robert N Piana
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Ravinder R Mallugari
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Daniel E Clark
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Jay N Patel
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Holly Gonzales
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Deepak K Gupta
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Anna Vatterott
- Division of Cardiology Department of Medicine Barnes-Jewish Hospital St. Louis MO
| | - Natalie Jackson
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN.,Structural Heart and Valve Center Vanderbilt University Medical Center Nashville TN
| | - Shi Huang
- Department of Biostatistics Vanderbilt University School of Medicine Nashville TN
| | - Brian R Lindman
- Division of Cardiology Department of Medicine Vanderbilt University Medical Center Nashville TN.,Structural Heart and Valve Center Vanderbilt University Medical Center Nashville TN
| |
Collapse
|
10
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EUROINTERVENTION 2022; 17:e1126-e1196. [PMID: 34931612 PMCID: PMC9725093 DOI: 10.4244/eij-e-21-00009] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
11
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg 2021; 60:727-800. [PMID: 34453161 DOI: 10.1093/ejcts/ezab389] [Citation(s) in RCA: 314] [Impact Index Per Article: 104.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
12
|
Vidula MK, Orlenko A, Zhao L, Salvador L, Small AM, Horton E, Cohen JB, Adusumalli S, Denduluri S, Kobayashi T, Hyman M, Fiorilli P, Magro C, Singh B, Pourmussa B, Greczylo C, Basso M, Ebert C, Yarde M, Li Z, Cvijic ME, Wang Z, Walsh A, Maranville J, Kick E, Luettgen J, Adam L, Schafer P, Ramirez-Valle F, Seiffert D, Moore JH, Gordon D, Chirinos JA. Plasma biomarkers associated with adverse outcomes in patients with calcific aortic stenosis. Eur J Heart Fail 2021; 23:2021-2032. [PMID: 34632675 DOI: 10.1002/ejhf.2361] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/25/2022] Open
Abstract
AIMS Enhanced risk stratification of patients with aortic stenosis (AS) is necessary to identify patients at high risk for adverse outcomes, and may allow for better management of patient subgroups at high risk of myocardial damage. The objective of this study was to identify plasma biomarkers and multimarker profiles associated with adverse outcomes in AS. METHODS AND RESULTS We studied 708 patients with calcific AS and measured 49 biomarkers using a Luminex platform. We studied the correlation between biomarkers and the risk of (i) death and (ii) death or heart failure-related hospital admission (DHFA). We also utilized machine-learning methods (a tree-based pipeline optimizer platform) to develop multimarker models associated with the risk of death and DHFA. In this cohort with a median follow-up of 2.8 years, multiple biomarkers were significantly predictive of death in analyses adjusted for clinical confounders, including tumour necrosis factor (TNF)-α [hazard ratio (HR) 1.28, P < 0.0001], TNF receptor 1 (TNFRSF1A; HR 1.38, P < 0.0001), fibroblast growth factor (FGF)-23 (HR 1.22, P < 0.0001), N-terminal pro B-type natriuretic peptide (NT-proBNP) (HR 1.58, P < 0.0001), matrix metalloproteinase-7 (HR 1.24, P = 0.0002), syndecan-1 (HR 1.27, P = 0.0002), suppression of tumorigenicity-2 (ST2) (IL1RL1; HR 1.22, P = 0.0002), interleukin (IL)-8 (CXCL8; HR 1.22, P = 0.0005), pentraxin (PTX)-3 (HR 1.17, P = 0.001), neutrophil gelatinase-associated lipocalin (LCN2; HR 1.18, P < 0.0001), osteoprotegerin (OPG) (TNFRSF11B; HR 1.26, P = 0.0002), and endostatin (COL18A1; HR 1.28, P = 0.0012). Several biomarkers were also significantly predictive of DHFA in adjusted analyses including FGF-23 (HR 1.36, P < 0.0001), TNF-α (HR 1.26, P < 0.0001), TNFR1 (HR 1.34, P < 0.0001), angiopoietin-2 (HR 1.26, P < 0.0001), syndecan-1 (HR 1.23, P = 0.0006), ST2 (HR 1.27, P < 0.0001), IL-8 (HR 1.18, P = 0.0009), PTX-3 (HR 1.18, P = 0.0002), OPG (HR 1.20, P = 0.0013), and NT-proBNP (HR 1.63, P < 0.0001). Machine-learning multimarker models were strongly associated with adverse outcomes (mean 1-year probability of death of 0%, 2%, and 60%; mean 1-year probability of DHFA of 0%, 4%, 97%; P < 0.0001). In these models, IL-6 (a biomarker of inflammation) and FGF-23 (a biomarker of calcification) emerged as the biomarkers of highest importance. CONCLUSIONS Plasma biomarkers are strongly associated with the risk of adverse outcomes in patients with AS. Biomarkers of inflammation and calcification were most strongly related to prognosis.
Collapse
Affiliation(s)
- Mahesh K Vidula
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alena Orlenko
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lei Zhao
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Lisa Salvador
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Aeron M Small
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward Horton
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Srinivas Denduluri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Hyman
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Fiorilli
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline Magro
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bibi Singh
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Bianca Pourmussa
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Candy Greczylo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael Basso
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Melissa Yarde
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Zhuyin Li
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Zhaoqing Wang
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Alice Walsh
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Ellen Kick
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - Leonard Adam
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Peter Schafer
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | | | | | - Jason H Moore
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David Gordon
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
| | - Julio A Chirinos
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
13
|
Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2021; 43:561-632. [PMID: 34453165 DOI: 10.1093/eurheartj/ehab395] [Citation(s) in RCA: 2266] [Impact Index Per Article: 755.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
|
14
|
Wozolek A, Jaquet O, Donneau AF, Lancellotti P, Legoff C, Cavalier E, Radermecker MA, Lavigne JP, Durieux R, Roediger L, Senard M, Hubert MB, Brichant JF, Amabili P, Hans GA. Cardiac Biomarkers and Prediction of Early Outcome After Heart Valve Surgery: A Prospective Observational Study. J Cardiothorac Vasc Anesth 2021; 36:862-869. [PMID: 34301449 DOI: 10.1053/j.jvca.2021.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/08/2021] [Accepted: 06/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Circulating cardiac biomarkers may improve the prediction of long-term outcomes after cardiac surgery. The authors sought to assess if cardiac biomarkers also help better predict short-term morbidity. DESIGN Prospective observational study. SETTING Single academic hospital. PARTICIPANTS A total of 250 patients undergoing aortic or mitral valve surgery with or without associated coronary artery bypass grafts. INTERVENTION None MEASUREMENT AND MAIN RESULTS: Relationships between preoperative plasma concentrations of four cardiac biomarkers (sST2, Galectin-3, GDF-15, and NT-proBNP) and postoperative outcome were assessed using logistic regressions and Cox proportional hazards models. The primary outcome was a composite of 30-day mortality, an inotropic support longer than 48 hours and an initial length of stay in the intensive care >five days. Secondary outcome measures were postoperative acute kidney injury, inotropic support duration, lengths of intensive care unit and hospital stays, and 30-day and one-year mortality. No association was observed between any of the four cardiac biomarkers and the primary outcome. The preoperative levels of Galectin-3 (hazard ratio = 1.2; p < 0.001) and sST2 (hazard ratio = 1.01, p < 0.001) were significantly associated with one-year survival, and their addition to the EuroSCORE II significantly improved the prediction of one-year mortality (p < 0.001). Similarly, Galectin-3 was associated with postoperative acute kidney injury (odds ratio = 1.15, p = 0.001) and improved the prediction of this complication when added to the EuroSCORE II (p = 0.002). CONCLUSIONS These results suggested that the ability of cardiac biomarkers to predict short-term outcome after cardiac surgery, though of interest, appears limited. Conversely, cardiac biomarkers may have the potential to refine the prediction of long-term outcome. Admittedly, all positive results were obtained on secondary outcomes and must be regarded with caution.
Collapse
Affiliation(s)
- Aaron Wozolek
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | - Oceane Jaquet
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | | | | | - Caroline Legoff
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Marc A Radermecker
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium; Department of Public Health, University of Liège, Liège, Belgium; Department of Cardiovascular and Thoracic Surgery, CHU of Liège, Liège, Belgium; Department of Cardiology, CHU of Liège, Liège, Belgium; Department of Clinical Chemistry, University of Liège, CHU de Liège, Liège, Belgium
| | - Jean-Paul Lavigne
- Department of Cardiovascular and Thoracic Surgery, CHU of Liège, Liège, Belgium
| | - Rodolphe Durieux
- Department of Cardiovascular and Thoracic Surgery, CHU of Liège, Liège, Belgium
| | - Laurence Roediger
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | - Marc Senard
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | - Marie Bernard Hubert
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | | | - Philippe Amabili
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium
| | - Grégory A Hans
- Department of Anesthesia and Intensive Care Medicine, CHU of Liège, Liège, Belgium.
| |
Collapse
|
15
|
White M, Baral R, Ryding A, Tsampasian V, Ravindrarajah T, Garg P, Koskinas KC, Clark A, Vassiliou VS. Biomarkers Associated with Mortality in Aortic Stenosis: A Systematic Review and Meta-Analysis. Med Sci (Basel) 2021; 9:medsci9020029. [PMID: 34067808 PMCID: PMC8163007 DOI: 10.3390/medsci9020029] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal timing of aortic valve replacement (AVR) remains controversial. Several biomarkers reflect the underlying pathophysiological processes in aortic stenosis (AS) and may be of use as mortality predictors. The aim of this systematic review and meta-analysis is to evaluate the blood biomarkers utilised in AS and assess whether they associate with mortality. PubMed and Embase were searched for studies reporting baseline biomarker level and mortality outcomes in patients with AS. A total of 83 studies met the inclusion criteria and were systematically reviewed. Of these, 21 reporting brain natriuretic peptide (BNP), N-terminal pro B-type natriuretic peptide (NT-proBNP), Troponin and Galectin-3 were meta-analysed. Pooled analysis demonstrated that all-cause mortality was significantly associated with elevated baseline levels of BNP (HR 2.59; 95% CI 1.95–3.44; p < 0.00001), NT-proBNP (HR 1.73; 95% CI 1.45–2.06; p = 0.00001), Troponin (HR 1.65; 95% CI 1.31–2.07; p < 0.0001) and Galectin-3 (HR 1.82; 95% CI 1.27–2.61; p < 0.001) compared to lower baseline biomarker levels. Elevated levels of baseline BNP, NT-proBNP, Troponin and Galectin-3 were associated with increased all-cause mortality in a population of patients with AS. Therefore, a change in biomarker level could be considered to refine optimal timing of intervention. The results of this meta-analysis highlight the importance of biomarkers in risk stratification of AS, regardless of symptom status.
Collapse
Affiliation(s)
- Madeline White
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
| | - Ranu Baral
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
- Norfolk and Norwich University Hospital, Norwich NR4 7UQ, UK
| | - Alisdair Ryding
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
- Norfolk and Norwich University Hospital, Norwich NR4 7UQ, UK
| | - Vasiliki Tsampasian
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
- Norfolk and Norwich University Hospital, Norwich NR4 7UQ, UK
- Correspondence:
| | - Thuwarahan Ravindrarajah
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
| | - Pankaj Garg
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
- Norfolk and Norwich University Hospital, Norwich NR4 7UQ, UK
| | | | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
| | - Vassilios S. Vassiliou
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7UQ, UK; (M.W.); (R.B.); (A.R.); (T.R.); (P.G.); (A.C.); (V.S.V.)
- Norfolk and Norwich University Hospital, Norwich NR4 7UQ, UK
| |
Collapse
|
16
|
Tschumper M, Weber L, Rickli H, Seidl S, Brenner R, Buser M, Ehl NF, Jäger-Rhomberg F, Ammann P, Maeder MT. Corrected QT Interval in Severe Aortic Stenosis: Clinical and Hemodynamic Correlates and Prognostic Impact. Am J Med 2021; 134:267-277. [PMID: 32621909 DOI: 10.1016/j.amjmed.2020.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The role of the electrocardiogram for risk stratification in patients with severe aortic stenosis is not established. We assessed the hemodynamic correlates and the prognostic value of the corrected QT interval (QTc) in patients with severe aortic stenosis undergoing aortic valve replacement. METHODS The QT interval was measured in a 12-lead electrocardiogram in 485 patients (age 74 ± 10 years, 57% male) with severe aortic stenosis (indexed aortic valve area 0.41 ± 0.13 cm2/m2, left ventricular ejection fraction 58 ± 12%) the day prior to cardiac catheterization. Prolonged QTc was defined as QTc >450 ms in men and QTc >470 ms in women. The outcome parameter was all-cause mortality. RESULTS Patients with prolonged QTc (n = 100; 77 men, 23 women) had similar indexed aortic valve area but larger left ventricular and left atrial size, lower left ventricular ejection fraction, more severe mitral regurgitation, lower cardiac index, and higher mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and pulmonary vascular resistance, as compared with patients with normal QTc (n = 385). After a median follow-up of 3.7 years (interquartile range, 2.6-5.2) after surgical (n = 349) or transcatheter (n = 136) aortic valve replacement, patients with prolonged QTc had higher mortality than those with normal QTc (hazard ratio 2.81 [95% confidence interval, 1.51-5.20]; P < .001). Prolonged QTc was an independent predictor of death along with more severe mitral regurgitation and higher pulmonary vascular resistance. CONCLUSIONS In patients with severe aortic stenosis, prolonged QTc is a marker of an advanced disease stage associated with an adverse hemodynamic profile and increased long-term mortality after aortic valve replacement.
Collapse
Affiliation(s)
- Maja Tschumper
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Internal Medicine, Spital Affoltern, Affoltern am Albis, Switzerland
| | - Lukas Weber
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Hans Rickli
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Sebastian Seidl
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roman Brenner
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marc Buser
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Niklas F Ehl
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Peter Ammann
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Micha T Maeder
- Cardiology Division, Kantonsspital St. Gallen, St. Gallen, Switzerland.
| |
Collapse
|
17
|
Romeo FJ, Seropian IM, Chiabrando JG, Raleigh JV, Smietniansky M, Cal M, Falconi M, Kotowicz V, Agatiello CR, Berrocal DH. Additive prognostic value of carbohydrate antigen-125 over frailty in patients undergoing transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2021; 97:E263-E273. [PMID: 32597028 DOI: 10.1002/ccd.29067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND To evaluate the additive prognostic value of myocardial, inflammatory, and renal biomarkers according to frailty status in patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS). METHODS A total of 111 subjects who underwent TAVR at Hospital Italiano de Buenos Aires, Argentina between January 2016 and December 2018 were retrospectively reviewed. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high sensitivity troponin T (hs-cTnT), C-reactive protein (CRP), cystatin-c (Cys-C) and carbohydrate antigen-125 (CA-125) were assessed prior to TAVR. Frailty status was assessed according to the fried physical frailty phenotype (FPFP). The primary endpoint was defined as all-cause death and/or readmission for worsening congestive heart failure (CHF) within the first year after TAVR. RESULTS Of the 111 patients included, 48/111 (43%) were considered to be "frail" according to the FPFP. Among biomarkers, we found CA-125 to be strongly associated with the primary endpoint (p = .006). CA-125 ≥ 18.2 U/ml was present in 41% and was associated with a higher rate of the primary endpoint (31% vs. 9%; p = .003). After multivariable adjustment, CA-125 ≥ 18.2 U/ml (hazard ratio [HR] 3.17; p = .024) was the only independent predictor of the primary endpoint. Finally, the inclusion of CA-125 to frailty significantly improved C-index (0.68-0.74; p < .05), and provided a Net Reclassification Improvement (NRI) of 0.34 (95% CI 0.19-0.49, p = .031), largely through reductions in risk estimates among pre-frail and frail patients. CONCLUSIONS CA-125, a tumor biomarker, outperformed frailty for predicting the primary endpoint within the first year after TAVR.
Collapse
Affiliation(s)
- Francisco José Romeo
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ignacio Miguel Seropian
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Guido Chiabrando
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Valle Raleigh
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Maximiliano Smietniansky
- Department of Internal Medicine and Geriatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mariela Cal
- Department of Internal Medicine and Geriatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mariano Falconi
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Vadim Kotowicz
- Department of Cardiovascular Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carla Romina Agatiello
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniel Horacio Berrocal
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
18
|
O'Leary JM, Clavel MA, Chen S, Goel K, O'Neill B, Elmariah S, Crowley A, Alu MC, Thourani VH, Leon MB, Pibarot P, Lindman BR. Association of Natriuretic Peptide Levels After Transcatheter Aortic Valve Replacement With Subsequent Clinical Outcomes. JAMA Cardiol 2020; 5:1113-1123. [PMID: 32667623 DOI: 10.1001/jamacardio.2020.2614] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Among those with aortic stenosis, natriuretic peptide levels can provide risk stratification, predict symptom onset, and aid decisions regarding the timing of valve replacement. Less is known about the prognostic significance and potential clinical utility of natriuretic peptide levels measured after valve replacement. Objective To determine the associations of elevated B-type natriuretic peptide (BNP) levels after transcatheter aortic valve replacement (TAVR) and change in BNP levels between follow-up time points with risk of subsequent clinical outcomes. Design, Setting, and Participants In this cohort study, patients with severe symptomatic aortic stenosis at intermediate, high, or prohibitive surgical risk for aortic valve replacement who underwent TAVR from the PARTNER IIA cohort, PARTNER IIB cohort, SAPIEN 3 intermediate-risk registry, and SAPIEN 3 high-risk registry were included. B-type natriuretic peptide levels were obtained at baseline and discharge as well as 30 days and 1 year after TAVR. For each measurement, a BNP ratio was calculated using measured BNP level divided by the upper limit of normal for the assay used. Outcomes were evaluated in landmark analyses out to 2 years. Data were collected from April 2011 to January 2019. Main Outcomes and Measures All-cause death, cardiovascular death, rehospitalization, and the combined end point of cardiovascular death or rehospitalization. Results Among 3391 included patients, 1969 (58.1%) were male, and the mean (SD) age was 82 (7.5) years. Most patients had a BNP ratio greater than 1 at each follow-up time point, including 2820 of 3256 (86.6%) at baseline, 2652 of 2995 (88.5%) at discharge, 1779 of 2209 (80.5%) at 30 days, and 1799 of 2391 (75.2%) at 1 year. After adjustment, every 1-point increase in BNP ratio at 30 days (approximately equivalent to an increase of 100 pg/mL in BNP) was associated with an increased hazard of all-cause death (adjusted hazard ratio [aHR], 1.11; 95% CI, 1.07-1.15), cardiovascular death (aHR, 1.16; 95% CI, 1.11-1.21), and rehospitalization (aHR, 1.08; 95% CI, 1.03-1.14) between 30 days and 2 years. Among those with a BNP ratio of 2 or more at discharge, after adjustment, every 1-point decrease in BNP ratio between discharge and 30 days was associated with a decreased hazard of all-cause death (aHR, 0.92; 95% CI, 0.88-0.96) between 30 days and 2 years. Conclusions and Relevance Elevated BNP levels after TAVR was independently associated with increased subsequent mortality and rehospitalizations. Further studies to determine how best to mitigate this risk are warranted.
Collapse
Affiliation(s)
- Jared M O'Leary
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Cardiovascular Medicine Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Shmuel Chen
- Cardiovascular Research Foundation, New York, New York.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York
| | - Kashish Goel
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Cardiovascular Medicine Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian O'Neill
- Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Sammy Elmariah
- Interventional Cardiology and Structural Heart Disease, Massachusetts General Hospital, Boston.,Harvard Medical School, Cambridge, Massachusetts
| | - Aaron Crowley
- Cardiovascular Research Foundation, New York, New York
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York.,Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Brian R Lindman
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Cardiovascular Medicine Division, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
19
|
Baumgartner H, Iung B, Otto CM. Timing of intervention in asymptomatic patients with valvular heart disease. Eur Heart J 2020; 41:4349-4356. [DOI: 10.1093/eurheartj/ehaa485] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/08/2020] [Accepted: 05/24/2020] [Indexed: 01/12/2023] Open
Abstract
Abstract
Current management of valvular heart disease (VHD) seeks to optimize long-term outcome by timely intervention. Recommendations for treatment of patients with symptoms due to severe valvular disease are based on a foundation of solid evidence. However, when to intervene in asymptomatic patients remains controversial and decision requires careful individual weighing of the potential benefits against the risk of intervention and its long-term consequences. The primary rationale for earlier intervention is prevention of irreversible left ventricular (LV) myocardial changes that might result in later clinical symptoms and adverse cardiac events. A number of outcome predictors have been identified that facilitate decision-making. This review summarizes current recommendations and discusses recently published data that challenge them suggesting even earlier intervention. In adults with asymptomatic aortic stenosis (AS), emerging risk markers include very severe valve obstruction, elevated serum natriuretic peptide levels, and imaging evidence of myocardial fibrosis or increased extracellular myocardial volume. Currently, transcatheter aortic valve implantation (TAVI) is not recommended for treatment of asymptomatic severe AS although this may change in the future. In patients with aortic regurgitation (AR), the potential benefit of early intervention in preventing LV dilation and dysfunction must be balanced against the long-term risk of a prosthetic valve, a particular concern because severe AR often occurs in younger patients with a congenital bicuspid valve. In patients with mitral stenosis, the option of transcatheter mitral balloon valvotomy tilts the balance towards earlier intervention to prevent atrial fibrillation, embolic events, and pulmonary hypertension. When chronic severe mitral regurgitation is due to mitral valve prolapse, anatomic features consistent with a high likelihood of a successful and durable valve repair favour early intervention. The optimal timing of intervention in adults with VHD is a constantly changing threshold that depends not only on the severity of valve disease but also on the safety, efficacy, and long-term durability of our treatment options.
Collapse
Affiliation(s)
- Helmut Baumgartner
- Department of Cardiology III – Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149 Muenster, Germany
| | - Bernard Iung
- Cardiology Department, Bichat Hospital, APHP, Université de Paris, 46 Rue Henri Huchard, 75018 Paris, France
| | - Catherine M Otto
- Cardiology, University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195, USA
| |
Collapse
|
20
|
Spampinato RA, Bochen R, Sieg F, Weiss S, Kornej J, Haunschild J, von Aspern K, Strotdrees E, Noack T, Lehmann S, Etz C, Borger MA. Multi-biomarker mortality prediction in patients with aortic stenosis undergoing valve replacement. J Cardiol 2020; 76:154-162. [DOI: 10.1016/j.jjcc.2020.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/25/2019] [Accepted: 02/18/2020] [Indexed: 11/30/2022]
|
21
|
Haberman D, Chernin G, Meledin V, Zikry M, Shuvy M, Gandelman G, Goland S, George J, Shimoni S. Urea level is an independent predictor of mortality in patients with severe aortic valve stenosis. PLoS One 2020; 15:e0230002. [PMID: 32160250 PMCID: PMC7065786 DOI: 10.1371/journal.pone.0230002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/19/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Severe aortic stenosis (AS) is the most common valvular heart disease in the western world. Various factors are related to severe AS prognosis, including chronic kidney disease. The aim of this study was to evaluate the prognostic value of urea level in patients with severe AS. Methods We prospectively enrolled 142 patients (79.1±9.4 years, 88 women) with severe AS (mean valve area 0.67± 0.17 cm2). Clinical assessment, blood tests and echocardiography were performed at enrollment and follow up. The patient population was divided into low and high urea level groups, according to the median urea level at enrollment (72 patients, mean urea 35.5±6.2 mg/dL and 70 patients, mean urea 61.1±17.8 mg/dL, respectively). Hundred and twelve patients (79%) underwent aortic valve intervention. The primary endpoint was all-cause and cardiovascular mortality. Outcomes During follow-up of 37±19.5 months, 56 (37.1%) patients died, 39 due to cardiovascular causes. In univariate analysis, age, urea level, creatinine, New York Heart Association (NYHA) class and aortic valve intervention were associated with all-cause mortality. However, in multivariate analysis only aortic valve intervention and blood urea were independent predictors of all-cause mortality (HR 0.494; 95% CI 0.226–0.918, P = 0.026 and HR 1.015; 95% CI 1.003–1.029, P = 0.046 respectively). Urea level, NYHA class and age were also significant predictors of cardiovascular mortality. Whereas, in multivariate analysis, only urea level predicted cardiovascular mortality in these patients (HR 1.017; CI 1.003–1.031 P = 0.019). Conclusions Blood urea, a generally readily available and routinely determined marker of renal function, is an independent prognostic factor in patients with severe AS.
Collapse
Affiliation(s)
- Dan Haberman
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
- * E-mail:
| | - Gil Chernin
- Nephrology Department Kaplan Medical Center, Rehovot, Israel
- Heart Institute, Hadassah Medical Center, Jerusalem, Israel
| | - Valery Meledin
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Meital Zikry
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Mony Shuvy
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
- Heart Institute, Hadassah Medical Center, Jerusalem, Israel
| | - Gera Gandelman
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Sorel Goland
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Jacob George
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Sara Shimoni
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
- Hebrew University and Hadassah Medical School, Jerusalem, Israel
| |
Collapse
|
22
|
Lindman BR, Dweck MR, Lancellotti P, Généreux P, Piérard LA, O’Gara PT, Bonow RO. Management of Asymptomatic Severe Aortic Stenosis. JACC Cardiovasc Imaging 2020; 13:481-493. [DOI: 10.1016/j.jcmg.2019.01.036] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/02/2019] [Accepted: 01/22/2019] [Indexed: 12/19/2022]
|
23
|
|
24
|
Hollenberg SM, Warner Stevenson L, Ahmad T, Amin VJ, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Peterson PN, Reed BN, Roy CL, Storrow AB. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2019; 74:1966-2011. [PMID: 31526538 DOI: 10.1016/j.jacc.2019.08.001] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
25
|
A Stitch in Time: Biomarker-Guided Timing of Aortic Valve Replacement for Severe Aortic Stenosis? JACC Cardiovasc Interv 2018; 11:2182-2184. [PMID: 30409275 DOI: 10.1016/j.jcin.2018.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022]
|