Abstract
BackgroundConventional surgical risk scores lack accuracy in risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR).Elevated levels of midregional proadrenomedullin (MR-proADM) levels are associated with adverse outcome not only in patients with manifest chronic disease states, but also in the general population.ObjectivesWe investigated the predictive value of MR-proADM for mortality in an unselected contemporary TAVR population.MethodsWe prospectively included 153 patients suffering from severe aortic stenosis who underwent TAVR from September 2013 to August 2014. This population was compared to an external validation cohort of 205 patients with severe aortic stenosis undergoing TAVR. The primary endpoint was all cause mortality.ResultsDuring a median follow-up of 258 days, 17 out of 153 patients who underwent TAVR died (11%). Patients with MR-proADM levels above the 75th percentile (≥ 1.3 nmol/l) had higher mortality (31% vs. 4%, HR 8.9, 95% CI 3.0–26.0, P < 0.01), whereas patients with EuroSCORE II scores above the 75th percentile (> 6.8) only showed a trend towards higher mortality (18% vs. 9%, HR 2.1, 95% CI 0.8–5.6, P = 0.13). The Harrell’s C-statistic was 0.58 (95% CI 0.45–0.82) for the EuroSCORE II, and consideration of baseline MR-proADM levels significantly improved discrimination (AUC = 0.84, 95% CI 0.71–0.92, P = 0.01). In bivariate analysis adjusted for EuroSCORE II, MR-proADM levels ≥1.3 nmol/l persisted as an independent predictor of mortality (HR 9.9, 95% CI (3.1–31.3), P <0.01) and improved the model’s net reclassification index (0.89, 95% CI (0.28–1.59). These results were confirmed in the independent validation cohort.ConclusionsOur study identified MR-proADM as a novel predictor of mortality in patients undergoing TAVR. In the future, MR-proADM should be added to the commonly used EuroSCORE II for better risk stratification of patients suffering from severe aortic stenosis.
Highlights
Transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for patients with aortic stenosis at prohibitive, high or intermediate surgical risk [1,2,3]
We prospectively included 153 patients suffering from severe aortic stenosis who underwent transcatheter aortic valve replacement (TAVR) from September 2013 to August 2014
This population was compared to an external validation cohort of 205 patients with severe aortic stenosis undergoing TAVR
Summary
Transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for patients with aortic stenosis at prohibitive, high or intermediate surgical risk [1,2,3]. At present TAVR is performed with a low intra-procedural complication rate and very favorable 30-day outcome, TAVR-patients still face a high long-term mortality reaching up to 44% at 3 years. The risk-benefit evaluation for TAVR is mainly done on the basis of clinical judgment and surgical scoring systems such as the EuroSCORE II [9]. These commonly used risk scores have failed to truly predict long-term outcome in patients undergoing TAVR [10, 11]. Conventional surgical risk scores lack accuracy in risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR). Elevated levels of midregional proadrenomedullin (MR-proADM) levels are associated with adverse outcome in patients with manifest chronic disease states, and in the general population
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