Prognostic value of high-sensitive troponin T in patients with severe aortic stenosis undergoing valve replacement surgery

Background

Aortic stenosis (AS) is a well-known cause of mortality. We aimed to assess the prognostic value of high-sensitive troponin T (hs-TnT) in symptomatic patients with severe AS and preserved left ventricular ejection fraction (LVEF) after surgical aortic valve replacement (AVR).

Patients and methods

The study recruited patients with severe symptomatic AS fulfilling the inclusion criteria in the period between April 2020 and February 2022. Comprehensive echocardiography was done. The following parameters were assessed: AS severity, LV mass index (LVMI), left atrium volume index (LAVI), and LVEF. E/e' and LVEF were calculated using the biplane method of Simpsons. Global longitudinal strain (GLS) was assessed by speckle tracking echocardiography. Peripheral blood samples were collected for hs-TnT measurement. All patients underwent surgical AVR. The patients were followed for the following 6 months for major adverse cardiovascular events (MACE). MACE was defined as cardiac death, re-admission for congestive heart failure (CHF) and fatal arrhythmia.

Results

One hundred and eight patients (mean age = 58.7 ± 7.68 years) with severe AS were recruited. Seventeen patients presented with MACE including 8 cardiac deaths. We divided the patients into two groups based on the normal hs-TnT values. The Kaplan-Meier curve revealed a statistically significant difference in MACE rate among troponin groups (log-rank test = 5.06, p = 0.025). There was significant difference between both groups regarding GLS with smaller GLS in negative hs-TnT group. In multivariate analysis, GLS and hs-TnT were significantly associated with MACE (p = 0.022 and < 0.01 respectively). The cutoff value of hs-TnT of 238.25 had a sensitivity of 70% and a specificity of 81% for predicting future MACE. There was a significant correlation between GLS and troponin (p < 0.001).

Conclusions

hs-TnT is associated with bad short-term prognosis after AVR. hs-TnT and GLS could be significant predictors for future MACE in patients with severe symptomatic AS and preserved LVEF who underwent AVR. Elevated hs-TnT and impaired GLS could set an indication of early intervention in asymptomatic severe AS.

Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis

OBJECTIVE

The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype.

METHODS

We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage.

RESULTS

Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179).

CONCLUSIONS

The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.