Rise in postoperative BNP linked to higher mortality after transapical TAVR

Issue: June 2014

TORONTO — B-type natriuretic peptide values may be a useful marker for stratifying risk in patients with aortic stenosis who are undergoing transcatheter aortic valve replacement, according to new findings from the PARTNER trial.

Perspective from John D. Puskas, MD

Previous data have demonstrated that elevated B-type natriuretic peptide (BNP) levels predict outcomes in patients undergoing surgical aortic valve replacement. In addition, a rise in BNP after transfemoral TAVR has been linked to increased risk for death.

The current analysis was performed to examine the predictive role of pre- and postoperative BNP on transapical TAVR among patients enrolled in the premarket and Non-Randomized Continued Access portions of the PARTNER trial, according to the study abstract.

Sebastian Alejandro Iturra, MD, presented data on 991 patients who underwent transapical TAVR in the premarket and Non-Randomized Continued Access PARTNER trials at 25 centers from 2007 to 2011. All patients had measurements of preoperative BNP or its N-terminal fragment (NT-proBNP), and 811 patients had paired pre- and postoperative values measured at 1, 6 and 12 months after transapical TAVR. Follow-up was a minimum of 1 year.

Nearly half (48.7%) of patients experienced a rise in 30-day BNP or NT-proBNP compared with preoperative values. The remainder of patients (51.3%) experienced a decrease or no change in BNP from preoperative levels, according to Iturra, a fellow in TAVR surgery at Emory University.

Patients with elevated BNP at 30 days after transapical TAVR had significantly higher rates of mortality from any cause at 1 year compared with patients who experienced a decrease or no change in BNP (20.3% vs. 9.5%; P<.001). BNP elevation was also associated with significantly higher rates of mortality or repeat hospitalization at 1 year (34.2% vs. 17.9%; P<.001).

“Patients with rises in BNP had worse outcomes,” Iturra told Cardiology Today. “They face a greater risk of dying and greater risk of repeat hospitalizations.”

Patients with elevated postoperative BNP had higher ejection fraction during follow-up; however, improvements in postoperative left ventricular EF were enhanced in patients who experienced a decrease or no change in postoperative BNP.

The researchers observed no correlation between paravalvular regurgitation and transapical TAVR between the two groups.

These data point to the clinical value of BNP monitoring in patients with aortic stenosis who are undergoing valve replacement, Iturra said.

“We are looking at more possible predictors of which patients will do well with TAVR,” he added. – by Louise Gagnon

For more information:

Iturra SA. Poster #5. Presented at: American Association for Thoracic Surgery Annual Meeting; April 26-30, 2014; Toronto.

Disclosure: Iturra reports no relevant financial disclosures.

Perspective

John D. Puskas, MD

We know that elevated BNP prior to surgery is an indicator of HF. If it doesn’t fall after surgery, the patient has persistent or potentially worsening HF. The purpose of the TAVR is to get the patients out of HF. If there is enough [aortic paravalvular] regurgitation that the patient still has HF after TAVR, it is likely that these patients will show a higher BNP.

Elevated BNP is a potentially useful marker to tell us which patients have such significant postprocedural aortic regurgitation that re-intervention is necessary. This poster is hypothesis-generating, but the sample size is not big enough to be conclusive.

John D. Puskas, MD

Professor of Cardiothoracic Surgery

Icahn School of Medicine at Mount Sinai Hospital

Chairman, Department of Cardiothoracic Surgery

Mount Sinai at Beth Israel

Director, Coronary Revascularization Reference Center

Mount Sinai Health System

Disclosures: Puskas reports no relevant financial disclosures.