Preoperative NT-proBNP Levels Research Articles

Usefulness of the N-Terminal of the Prohormone Brain Natriuretic Peptide in Predicting Acute Kidney Injury Requiring Renal Replacement Therapy in Patients Undergoing Heart Valve Surgery.

Background and Objectives: By definition, acute kidney injury (AKI) is a clinical syndrome diagnosed when the increase in serum creatinine concentration is >0.3 mg/dL in 48 h or >1.5-fold in the last seven days or when diuresis < 0.5 mL/kg/h for a consecutive 6 h. AKI is one of the severe complications that may occur in the early postoperative period in patients undergoing heart valve surgery, significantly increasing the risk of death. Early implementation of renal replacement therapy increases the chances of improving treatment results in patients with postoperative AKI. The study assessed the predictive ability of selected preoperative and perioperative parameters for the occurrence of postoperative AKI requiring renal replacement therapy in the early postoperative period in a group of patients with severe valvular heart disease. Materials and Methods: A prospective study was conducted on a group of patients undergoing consecutive heart valve surgeries. The primary endpoint was postoperative AKI requiring renal replacement therapy. AKI was diagnosed with an increase in serum creatinine > 0.3 mg/dL in 48 h or >1.5-fold in the previous 7 days and/or a decrease in diuresis < 0.5 mL/kg/h for 6 h. The observation period was until the patient was discharged home or death occurred. Logistic regression analysis was used to assess which variables were predictive of primary endpoint, and odds ratios (OR) were calculated with a 95% confidence interval (CI). Multivariate analysis was based on the result of single factor logistic regression, i.e., to further steps, all statistically significant variables were taken into consideration. Results: A total of 607 patients were included in the study. The primary endpoint occurred in 50 patients. At multivariate analysis: NT-proBNP (OR 1.406; 95% CI 1.015-1.949; p = 0.04), CRP (OR 1.523; 95% CI 1.171-1.980; p = 0.001), EuroSCORE II (OR 1.090; 95% CI 1.014-1.172; p = 0.01), age (OR 1.037; 95% CI 1.001-1.075; p = 0.04) and if they stayed in the intensive care unit longer than 2 days (OR 9.077; 95% CI 2.026-40.663; p = 0.004) remained the independent predictors of the primary endpoint. The mean preoperative NT-proBNP level was 2063 pg/mL (±1751). Thirty-eight patients with AKI requiring renal replacement therapy died in intrahospital follow-up. Conclusions: The results of the presented study indicate that a high preoperative level of NT-proBNP and postoperative hemodynamic instability may be associated with a significant risk of a postoperative AKI requiring renal replacement therapy. The results of the study may also suggest that qualifying for heart valve surgery earlier may be associated with improved prognosis in this group of patients.

A Potential Marker for Prognosis in Giant Left Ventricular Patients Undergoing Valve Surgery

Background: Although many clinicians have made efforts to improve the prognosis for giant left ventricular with valve disease patients, potential markers to judge the prognosis of giant left ventricular patients undergoing valve surgery are still unknown. The purpose of this study was to explore the possible impact factors for giant left ventricle prognosis. Methods: From September 2019 to September 2022, 75 patients with preoperative valvular disease with a giant left ventricle (left ventricular end diastolic diameter (LVEDD) &gt;65 mm) underwent cardiac valve surgery. The changes in cardiac function one year after surgery were used to describe prognosis and analyze the potential independent factors affecting surgical prognosis. The left ventricular ejection fraction (LVEF) was considered to be recovered if it was ≥50% on follow-up echocardiography at least 6 months after the diagnosis. Results: The cardiac function of patients with a giant left ventricular and valve disease improved. Compared with preoperation, the left ventricular end diastolic diameter (LVEDD), left ventricular end-systolic dimension (LVESD), pulmonary artery systolic pressure (PASP), NT-proBNP, and cardio thoracic ratio (CTR) were significantly decreased (p &lt; 0.05), and the ratio of severe heart failure was decreased from 60% to 37.33%. In the univariate analyses, the preoperative NT-proBNP levels and PASP were significantly associated with the cardiac function recovery (odds ratio [OR] = 1.001, 95% CI 1.000–1.002, p = 0.027; OR = 1.092, 95% CI 1.015–1.175, p = 0.018). However, during the diagnostic test, PASP did not account for cardiac function recovery (AUROC = 0.505, 95% CI = 0.387–0.713, p = 0.531). Based on the cutoff value in the experiment, we found that a NT-proBNP &gt;753 pg/mL (AUROC = 0.851, 95% CI = 0.757–0.946, p &lt; 0.0001) was a potential prognostic marker for patients with a giant left ventricular valve disease. Conclusions: We have demonstrated that an elevated preoperative NT-proBNP level is an independent predictor of cardiac function recovery in a cohort of giant left ventricular patients undergoing valve surgery, and this is the first study about this specific cohort of patients.

Prognostic significance of the biomarker NT-proBNP in the surgical treatment of aortic stenosis (pilot study)

The objective was to study the relationship between the preoperative blood levels of the N-terminal segment of B-type natriuretic peptide precursor (NT-proBNP) and ultrasound and thermodilution indicators of cardiac function before and after on-pump surgery for aortic stenosis, as well as to evaluate the prognostic significance of the biomarker in relation to postoperative myocardial dysfunction.Materials and methods. The study involved 27 patients aged 57.7±2.5 years who underwent aortic valve replacement. NT-proBNP level was determined before surgery. The indicators of invasive hemodynamics and transesophageal echocardiography were analyzed at stages: I – after anesthesia induction, II – at the end of surgery. Correlation analysis, logistic regression and ROC analysis were used.Results. The preoperative NT-proBNP level was 2002.0 [540.8–4001.5] pg/ml. At I stage, NT-proBNP correlated with mean pulmonary artery pressure (rho = 0.468; p = 0.014), indices of left ventricular function (rho = –0.509; p = 0.007), end-diastolic and end-systolic volumes (rho = 0.737–0.757; p &lt; 0.0001), as well as ejection fraction (rho = –0.556; p = 0.004) and area contraction fraction (rho = –0.783; p &lt; 0.0001). At II stage, the level of NT-proBNP &gt; 2000 pg/ml was a predictor of the left ventricular area contraction fraction &lt; 50% (OR 1.0011, 95% CI 1.0002–1.0020, p = 0.028, AUC 0.799) , the left ventricular end-systolic area index &gt; 9 cm2/m2 (OR 1.0007, 95% CI 1.0001–1.0013, p = 0.027, AUC 0.886), vasoactive-inotropic score &gt; 10 (OR 1.0006, 95% CI 1.0001–1.0012, p = 0.032, AUC 0.876), duration of sympathomimetic therapy &gt; 24 h (OR 1.0001, 95% CI 1.0000–1.0003, p = 0.049, AUC 0.889).Conclusions. NT-proBNP blood level was increased in 66.7% of patients with aortic stenosis before surgery. Moreover, the biomarker level directly correlates with the mean pulmonary artery pressure, the indices of end-diastolic and end-systolic volumes, end-diastolic and end-systolic areas of the left ventricle, and it inversely correlates with the left ventricular stroke work index, ejection fraction and left ventricular area contraction fraction. The preoperative NT-proBNP level was a predictor of the postoperative decrease to the pathological level of the ejection fractions and left ventricular area contraction, an increase in the left ventricular end-systolic area index, intensive and prolonged sympathomimetic therapy. Myocardial dysfunctions were most pronounced in patients with biomarker levels above 2000 pg/ml.

Development and Validation of a Machine Learning Predictive Model for Cardiac Surgery-Associated Acute Kidney Injury.

We aimed to develop and validate a predictive machine learning (ML) model for cardiac surgery associated with acute kidney injury (CSA-AKI) based on a multicenter randomized control trial (RCT) and a Medical Information Mart for Intensive Care-IV (MIMIC-IV) dataset. This was a subanalysis from a completed RCT approved by the Ethics Committee of Fuwai Hospital in Beijing, China (NCT03782350). Data from Fuwai Hospital were randomly assigned, with 80% for the training dataset and 20% for the testing dataset. The data from three other centers were used for the external validation dataset. Furthermore, the MIMIC-IV dataset was also utilized to validate the performance of the predictive model. The area under the receiver operating characteristic curve (ROC-AUC), the precision-recall curve (PR-AUC), and the calibration brier score were applied to evaluate the performance of the traditional logistic regression (LR) and eleven ML algorithms. Additionally, the Shapley Additive Explanations (SHAP) interpreter was used to explain the potential risk factors for CSA-AKI. A total of 6495 eligible patients undergoing cardiopulmonary bypass (CPB) were eventually included in this study, 2416 of whom were from Fuwai Hospital (Beijing), for model development, 562 from three other cardiac centers in China, and 3517 from the MIMICIV dataset, were used, respectively, for external validation. The CatBoostClassifier algorithms outperformed other models, with excellent discrimination and calibration performance for the development, as well as the MIMIC-IV, datasets. In addition, the CatBoostClassifier achieved ROC-AUCs of 0.85, 0.67, and 0.77 and brier scores of 0.14, 0.19, and 0.16 in the testing, external, and MIMIC-IV datasets, respectively. Moreover, the utmost important risk factor, the N-terminal brain sodium peptide (NT-proBNP), was confirmed by the LASSO method in the feature section process. Notably, the SHAP explainer identified that the preoperative blood urea nitrogen level, prothrombin time, serum creatinine level, total bilirubin level, and age were positively correlated with CSA-AKI; preoperative platelets level, systolic and diastolic blood pressure, albumin level, and body weight were negatively associated with CSA-AKI. The CatBoostClassifier algorithms outperformed other ML models in the discrimination and calibration of CSA-AKI prediction cardiac surgery with CPB, based on a multicenter RCT and MIMIC-IV dataset. Moreover, the preoperative NT-proBNP level was confirmed to be strongly related to CSA-AKI.

Risk Factors of Sudden Cardiac Arrest during the Postoperative Period in Patient Undergoing Heart Valve Surgery

Sudden cardiac arrest (SCA) is the sudden cessation of normal cardiac activity with hemodynamic collapse. This usually leads to sudden cardiac death (SCD) when cardiopulmonary resuscitation is not undertaken. In patients undergoing heart valve surgery, postoperative SCA is a complication with a high risk of death, cerebral hypoxia and multiple organ dysfunction syndrome (MODS). Therefore, knowledge of the predictors of postoperative SCA is extremely important as it enables the identification of patients at risk of this complication and the application of the special surveillance and therapeutic management in this group of patients. The aim of the study was to evaluate the usefulness of selected biomarkers in predicting postoperative SCA in patients undergoing heart valve surgery. This prospective study was conducted on a group of 616 consecutive patients with significant valvular heart disease that underwent elective valve surgery with or without coronary artery bypass surgery. The primary end-point at the intra-hospital follow-up was postoperative SCA. The secondary end-point was death from all causes in patients with postoperative SCA. Patients were observed until discharge from the hospital or until death. Logistic regression was used to assess the relationships between variables. The postoperative SCA occurred in 14 patients. At multivariate analysis, only NT-proBNP (odds ratio (OR) 1.022, 95% confidence interval (CI) 1.012-1.044; p = 0.03) remained independent predictors of the primary end-point. Age and NT-proBNP were associated with an increased risk of death in patients with postoperative SCA. The results of the presented study indicate that SCA in the early postoperative period in patients undergoing heart valve surgery is an unpredictable event with high mortality. The potential predictive ability of the preoperative NT-proBNP level for the occurrence of postoperative SCA and death in patients after SCA demonstrated in the study may indicate that the overloaded and damaged myocardium in patients undergoing heart valve surgery is particularly sensitive to non-physiological conditions prevailing in the perioperative period, which may cause serious hemodynamic disturbances in the postoperative period and lead to death.

Diagnostic accuracy of copeptin and NT-proBNP level in predicting mortality and postoperative prognosis in coronary surgery with respect to EuroSCORE risk.

During the last few years, many modifications in risk stratification of all cardiac surgical patients have been reported based on EuroSCORE. In this study we aimed to interpret copeptin and NT-proBNP levels in patients who had undergone coronary surgery with respect to EuroSCORE. We investigated the correlation between pre-operative copeptin and NT-proBNP levels with respect to mortality and post-operative complications via EuroSCORE II in the 484 enrolled patients. In terms of analyzing mortality the first 30 days were taken into account and duration of hospital stay was considered for prognosis. The statistical significance of copeptin and NT-proBNP with respect to EuroSCORE II ≥ 2 was studied. The critical threshold levels of mortality for NT-proBNP was 1296 pg/ml and for copeptin was 116 pmol/l in patients whose EuroSCORE II ≥ 2. Mortality increases 9.04-fold in cases with EuroSCORE ≥ 2, 5.04-fold when NT-proBNP level is > 1296 pg/ml. A dramatic outcome was observed in copeptin levels as mortality increased 138.17-fold when copeptin was > 116 pmol/l. Increased levels of copeptin and NT-proBNP negatively affect mortality and complication rates in isolated cardiac surgery patients.

N-Terminal Pro-B-Type Natriuretic Peptide as a Predictor of Adverse Outcomes After Off-Pump Coronary Artery Bypass Surgery: A Prospective Study

The strength of association between preoperative natriuretic peptide levels and adverse outcomes after cardiac surgery recently has been studied in different research, but results still are diversely variable. Sixty-five consecutive patients undergoing elective off-pump coronary artery bypass grafting prospectively were recruited. Preoperative levels of NTproBNP were measured in venous blood samples collected before induction of anesthesia. The average age was 57.62 ± 7.21. Of the patients, 86.15% were male. Euro-scoreII averaged 1.76 ± 0.34. The mean preoperative NTproBNP levels were 312.41 ± 329.93 pg/mL. Only two patients died (3%). Three patients required prolonged mechanical ventilation (4.6%). Four patients (6%) suffered from new onset postoperative AF. Five patients (7.6%) had low cardiac output, of which three needed IABP, and four patients (6%) had postoperative myocardial infarction. The mean ICU stay was 3.37 ± 0.84 days, and the mean hospital stay was 6.38 ± 1.3 days. There were no significant differences in preoperative NTproBNP levels in patients who had or didn't have any of the postoperative complications or in-hospital mortality (P > .05). Our study showed no significant correlation between preoperative NTproBNP levels and postoperative low cardiac output, atrial fibrillation, postoperative myocardial infarction, length of ICU stay, prolonged mechanical ventilation, length of hospital stay as well as in-hospital mortality following elective off-pump CABG. Therefore, more prospective specific studies are needed to delineate the role of preoperative natriuretic peptides as significant predictors of poor outcomes after CABG surgery.

Prevalence and prognostic implications of increased apical basal strain ratio in aortic stenosis undergoing transcatheter aortic valve replacement

Abstract Background A substantial number of elderly patients with aortic stenosis (AS) have been reported to have coexisting transthyretin cardiac amyloidosis (ATTR). These patients are characterized by advanced heart failure symptoms and increased NTproBNP. Raising clinical suspicion of ATTR in AS patients seems difficult. Recent data has shown that an increased apical-basal strain ratio (ABr) derived by echocardiography predicts the diagnosis of cardiac amyloidosis (CA) in patients with left ventricular (LV) hypertrophy. However, the prevalence and prognostic value of ABr, a potential marker of ATTR, in patients with symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) is unknown. The aim of this study was to investigate the preoperative prevalence, relation to symptoms and prognostic implications of elevated ABr in patients with symptomatic AS undergoing TAVR. Methods We obtained data including survival status from 499 consecutive AS patients who underwent TAVR in the period 2016–2018 at our institution. From 2D echocardiographic apical images ABr was calculated as mean longitudinal strain of the 5 LV apical segments divided by the mean of the 6 LV basal segments. Patients were stratified according to ABr; 0–1.9 was considered normal, 2–2.9 mildly increased, 3.0–3.9 moderately increased and ≥4 severely increased. Results Median follow-up time was 743 days. Mean age was 80±7 years. The prevalence of ABr ≥4 was 16% (n=78). These patients had higher preoperative NYHA class (77% were NYHA III or IV compared to 59% in ABr 0–1.9, p=0.003). Median preoperative NTproBNP levels for ABr ≥4 were 1781 pmol/l compared to 876 pmol/l in ABr 0–1.9 (p=0.003). NTproBNP levels decreased for all ABr subgroups at three months follow-up but remained considerably elevated in ABr ≥4 (median of ABr ≥4 was 1262 pmol/l compared to 645 pmol/l for ABr 0–1.9, p=0.001). LV ejection fraction (EF) in ABr 0–1.9 and ≥4 was 50% and 46%, p=0.014. The preoperative aortic valve stenosis severity derived by echo Doppler parameters were comparable across ABr subgroups. Overall, increased ABr ≥4 was associated with poor survival (fig. 1). In univariate analysis ABr ≥4 (HR 1.90, p=0.018), preoperative NTproBNP levels above the median of 1226 pmol/l (HR 3.14, p=0.003), increasing age (HR 1.05, p=0.018), TAPSE &amp;lt;19 mm (HR 1.91, p=0.011) and LV EF &amp;lt;50% (HR 1.60, p=0.045) were significant predictors of mortality. Preoperative NTproBNP &amp;gt;1226 pmol/l emerged as the only significant outcome predictor in a multivariate analysis (HR 2.67, p=0.029). Conclusion Increased ABr ≥4 occurs frequently and is associated with significantly higher pre- and postoperative NYHA class, NTproBNP levels and reduced survival in symptomatic AS patients undergoing TAVR. Some of these patients might have undiagnosed CA. The echocardiographic derived ABr could in future studies prove to be a useful tool in raising suspicion of ATTR leading to referral for diagnostic testing for CA. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Danish Independent Research Fund

Impact of diastolic dysfunction on long-term mortality and quality of life after transcatheter aortic valve replacement.

There is conflicting data as to whether diastolic dysfunction (DD) affects the prognosis of patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Consecutive patients undergoing TAVR underwent assessment of DD with preoperative echocardiography and NT-pro BNP. Long-term survival was ascertained every 6 months by clinic visits or phone. DD was graded according to the new American Society of Echocardiography recommendations. Health status was assessed at baseline and 30 days post-procedure using the KCCQ-12 questionnaire. Long-term survival was displayed using Kaplan-Meier curves according to NT-pro BNP levels and DD grades. We included 222 patients, mean age 78 (±8) years, median STS score 4 (interquartile range = 3-7), median follow-up time 385 days (IQR = 180-640). DD was absent in 25, Grade I in 13, Grade II in 74, Grade III in 24, and indeterminate in 86 patients. Advanced (Grades II-III) DD was associated with higher pre-procedural NT-pro BNP levels (p < .001), worse quality of life (p < .001) but similar surgical risk (p = .43). Advanced and indeterminate DD were associated with increased long-term mortality (25-28% vs. 5%, p = .02) and elevated NT-pro BNP levels (26.4% vs. 9.8%, p = .05). Improvements in quality of life measures were seen in all DD groups (median change in KCCQ score no or Grade I DD:14 [3-21] vs. Grades II-III DD: 15 [16-26; p = .37]). Preoperative NT-pro BNP levels and echocardiographic indices of indeterminate or advanced DD are associated with increased long-term mortality after TAVR but similar improvements in quality of life.

Impact of underlying heart disease per se on the utility of preoperative NT-proBNP in adult cardiac surgery

ObjectiveThe primary aim was to investigate the role of underlying heart disease on preoperative NT-proBNP levels in patients admitted for adult cardiac surgery, after adjusting for the known confounders age, gender, obesity and renal function. The second aim was to investigate the predictive value of preoperative NT-proBNP with regard to severe postoperative heart failure (SPHF) and postoperative mortality.MethodsA retrospective cohort study based on preoperative NT-proBNP measurements in an unselected cohort including all patients undergoing first time surgery for coronary artery disease (CAD; n = 2226), aortic stenosis (AS; n = 406) or mitral regurgitation (MR; n = 346) from April 2010 to August 2016 in the southeast region of Sweden (n = 2978). Concomitant procedures were not included, with the exception of Maze or tricuspid valve procedures.ResultsPreoperative NT-proBNP was 1.67 times (p<0.0001) and 1.41 times (p<0.0001) higher in patients with AS or MR respectively, than in patients with CAD after adjusting for confounders.NT-proBNP demonstrated significant discrimination with regard to SPHF in CAD (AUC = 0.79, 95%CI 0.73–0.85, p<0.0001), MR (AUC = 0.80, 95%CI 0.72–0.87, p<0.0001) and AS (AUC = 0.66, 95%CI 0.51–0.81, p = 0.047). In CAD patients NT-proBNP demonstrated significant discrimination with regard to postoperative 30-day or in-hospital mortality (AUC = 0.78; 95%CI 0.71–0.85, p<0.0001). The number of deaths was too few in the AS and MR group to permit analysis. Elevated NT-proBNP emerged as an independent risk factor for SPHF, and postoperative mortality in CAD.ConclusionsPatients with AS or MR have higher preoperative NT-proBNP than CAD patients even after adjusting for confounders. The predictive value of NT-proBNP with regard to SPHF was confirmed in CAD and MR patients but was less convincing in AS patients.

The Predictive Value of Preoperative Serum NTproBNP Levels for the Need for Inotropic Support in the Postoperative Period in Patients Undergoing Coronary Artery Bypass Grafting

Background: High preoperative BNP levels can be a marker of higher risk for coronary artery bypass grafting. We investigated the predictive value of serum NT-proBNP levels undergoing coronary artery bypass grafting for the need for inotropic support. Methods: In this prospective study, preoperative serum NT-proBNP levels were obtained in 51 patients [80.4% (n=42) were males and 19.6% (n=9) were females] undergoing isolated coronary artery bypass grafting. The study patients were divided into three groups depending on NT-proBNP levels as low NT-proBNP (&lt;100 pg/ml, Group-1, 29.4%, n=15) group, moderately high NT-proBNP (NT-proBNP &lt;500 pg/mL and &gt;100 pg/mL, Group-2, 29.4%, n=15) group, and high NT-proBNP (&gt;500 pg/mL, Group-3, 41.2%, n=21) group.Results: At postoperative day 0, the mean adrenalin, dopamine, dobutamine, and noradrenalin consumptions were 0.1±0.7 microgram/kg/min, 0.08±0.56 microgram/kg/min, 2.1±3.01 microgram/ kilogram/min, and 1.35±3.45 microgram/kg/min, respectively. There were no statistically significant differences between the groups in terms of the use of adrenalin (p=0.50, p&gt;0.05), dopamine (p=0.31 p&gt;0.05), dobutamine (p=0.59 p&gt;0.05), and noradrenalin (p=0.24 p&gt;0.05) at postoperative day 0. The doses of inotropic agents used at postoperative days 1 and 2 did not show significant differences between the groups for the three inotropic agents.Conclusion: Preoperative serum NT-proBNP levels in patients undergoing coronary artery bypass grafting are not associated with the need for inotropic support in the postoperative period.Cardiovasc. j. 2017; 9(2): 90-96

Preoperative Serum NT-proBNP levels; Can it be a Clue About Postoperative Clinical Outcome of Patients Undergoing to Coronary Artery Bypass Surgery?

Preoperative Serum NT-proBNP levels; Can it be a Clue About Postoperative Clinical Outcome of Patients Undergoing to Coronary Artery Bypass Surgery?

Predicting Device Success and Early Clinical Outcome after Transapical Aortic Valve Implantation

Objective: Pre-procedural evaluation of aortic valve patients is based on the prediction of perioperative risk for a conventional aortic valve replacement (AVR) utilizing standardized risk scores. However, in in the era of transcatheter aortic valve implantation (TAVI) the specific prediction of procedural outcome of an interventional approach seems of growing importance. We aimed to isolate patient- and approach-related factors, predicting procedural outcome of transapical aortic valve implantation (TA-TAVI), especially focusing on parameters not included in standard risk scores (e.g. BMI, intracardiac anatomy, preoperative NT-proBNP). Methods: A cohort of 60 patients suffering from severe aortic stenosis and receiving TA-TAVI at our institution was analyzed (mean age was 77.7 ± 6.3 years, 50% male). All patients exhibited a high risk for conventional AVR (EuroScorelog ≥ 20 or porcelain aorta) and were scheduled for a TA approach using an Edwards Sapien valve following heart-team discussion. Prior the procedure, all patients underwent multi-slice computed tomography examination. In order to evaluate the procedural and clinical outcome after TA-TAVI, three endpoints were defined: More than mild postoperative paravalvular leak (PVL), postoperative mean transvalvular gradient > 14 mmHg and a composite endpoint of 30-day mortality, stroke and myocardial infarction. For isolation of outcome predictors, fourteen different potential predictors were included into primary univariate regression analyses, seven of which entered subsequent multivariate analyses. Results: A BMI ≥ 30 was found in multivariate logistic regression to double the risk for both more than mild PVL and higher postoperative transvalvular gradients, however without reaching statistical significance (OR 2.57 95% CI 0.69-9.52; p=0.157 and OR 2.32 95% CI 0.57-9.45; p=0.242, respectively). Male gender and COPD were both associated with a decreased risk for elevated postoperative gradients. Of the analyzed approach-related parameters, especially a LVOT-aorta angle <120° was associated with an increased risk of the composite end-point (OR 6.65 95% CI 0.93-47.4; p=0.059). Furthermore preoperative NT-proBNP levels <400 ng/ml were found to predict a trend towards higher postoperative transvalvular gradients (OR 5.15 95% CI 0.32-81.9; p=0.246). Conclusion: Standardized risk scores for conventional AVR are limited in terms of predicting the early outcome of TAVI procedures. The current study provides evidence that specific parameters such as the LVOT-aorta angle are likely to improve outcome prediction of patients undergoing TAVI procedures.

0058 : Low circulating levels of Growth Differentiation Factor 15 (GDF-15) before coronary artery bypass surgery may predict post-operative atrial fibrillation

Post-operative atrial fibrillation (POAF) following cardiac surgery has a high prevalence and is associated with considerable morbidity. To assess the role of GDF-15, a member of the TGFβsuperfamily, as a potential new predictor of POAF after off-pump (OFP) and on-pump (ONP) coronary artery bypass graft (CABG) surgery. This observational study recruited the first 50 patients planned for OFP surgery and the first 50 patients planned for ONP surgery. Patients referred for CABG with the following exclusion criteria: age <18 or >80 years, previous atrial fibrillation/flutter, previous treatment with Amiodarone, previous cardiac surgery, emergency surgery. Included patients were equipped with long-duration (7 days) Holter ECG monitoring. POAF was defined as an AF episode lasting >30 seconds. All patients underwent pre-operative echocardiography to assess LVEF and left atrial diameter. GDF-15 levels were assessed at induction of anaesthesia and 12 hours after the end of surgery. Among the 100 patients, 34 developed POAF. In Cox multivariate regression analysis, the EuroSCORE, left atrial diameter>45mm and low GDF- 15 levels at induction (<1200 ng/l) were independently associated with the onset of POAF. When comparing the incremental prognostic value of GDF-15 according to the time of blood sampling, we found that a low circulating level of GDF-15 at induction was a better predictor of POAF than that 12h later. In contrast, pre-operative NT-proBNP levels did not predict POAF. The use of ONP surgery was not associated with a higher incidence of POAF, even though baseline and follow-up characteristics in ONP and OFP patients were identical. In patients with no history of AF, a low plasma level of GDF- 15 before CABG surgery was a strong and independent predictor of POAF. Moreover, preoperative plasma GDF-15 levels added an incremental predictive value to classical risk factors of POAF.

Prediction of perioperative cardiac events through preoperative NT-pro-BNP and cTnI after emergent non-cardiac surgery in elderly patients.

ObjectivesClinical risk stratification has an important function in preoperative evaluation of patients at risk for cardiac events prior to non-cardiac surgery. The aim of this study was to determine whether the combined measurement of pre-operative N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and cardiac troponin I (cTnI) could provide useful prognostic information about postoperative major adverse cardiac events (MACE) within 30 days in patients aged over 60 years undergoing emergent non-cardiac surgery.MethodsThe study group comprised 2519 patients aged over 60 years that were undergoing emergent non-cardiac surgery between December 2007 and December 2013. NT-pro-BNP and cTnI were measured during hospital admission. The patients were monitored for MACE (cardiac death, non-fatal myocardial infarction, or cardiac arrest) during the 30-day postoperative follow-up period.ResultsMACE occurred in 251 patients (10.0%). Preoperative NT-pro-BNP and cTNI level were significantly higher in the individuals that experienced MACE than in those who did not (P < 0.001). The confounding factors of age, sex, co-morbidities and preoperative medications were adjusted in a multivariate logistic regression analysis. This analysis showed that preoperative NT-proBNP level > 917 pg/mL (OR 4.81, 95% CI 3.446–6.722, P < 0.001) and cTnI ≥ 0.07 ng/mL (OR 8.74, 95% CI 5.881–12.987, P < 0.001) remained significantly and independently associated with MACE after the adjustment of the confounding factors. Kaplan-Meier event-free survival curves demonstrated that patients with preoperative simultaneous NT-proBNP level > 917 pg/mL and cTnT ≥0.07 ng/mL had worse event-free survival than individual assessments of either biomarker.ConclusionPreoperative plasma NT-proBNP and cTnI are both independently associated with an increased risk of MACE in elderly patients after emergent non-cardiac surgery. The combination of these biomarkers provides better prognostic information than using either biomarker separately.

Low Circulating Levels of Growth Differentiation Factor-15 Before Coronary Artery Bypass Surgery May Predict Postoperative Atrial Fibrillation.

To assess the role of growth differentiation factor-15 (GDF-15) as a potential new predictor of postoperative atrial fibrillation (POAF) after off-pump (OFP) and on-pump (ONP) coronary artery bypass graft (CABG) surgery. Prospective, single-center, observational study. University teaching hospital. The first 50 patients planned for OFP surgery and the first 50 patients planned for ONP surgery among patients referred for CABG with the following exclusion criteria: age<18 or>80 years, previous atrial fibrillation/flutter, previous treatment with amiodarone, previous cardiac surgery, and emergency surgery. Included patients were equipped with long-duration (7 days) Holter-ECG monitoring. POAF was defined as an AF episode lasting>30 seconds. All patients underwent preoperative echocardiography to assess left ventricular ejection fraction and left atrial diameter. GDF-15 levels were assessed after induction of anesthesia and 12 hours after arrival at the intensive care unit. Among the 100 patients, 34 (34%) developed POAF. In Cox multivariate regression analysis, the EuroSCORE, left atrial diameter>45 mm, and low GDF-15 levels at induction were associated independently with the onset of POAF. In contrast, preoperative NT-proBNP levels did not predict POAF. The use of ONP surgery was not associated with a higher incidence of POAF, even though baseline and follow-up characteristics in ONP and OFP patients were identical. In patients with no history of AF, a low plasma level of GDF-15 before CABG surgery was a strong independent predictor of POAF. Moreover, preoperative plasma GDF-15 levels added an incremental predictive value to classic risk factors of POAF.

Postoperative N-terminal Pro–Brain Natriuretic Peptide Level in Coronary Artery Bypass Surgery With Ventricular Dysfunction After Perioperative Glucose-Insulin-Potassium Treatment

The aim of this study was to clarify the efficacy of perioperative glucose-insulin-potassium (GIK) infusion on preoperative and postoperative N-terminal (NT)-pro-brain natriuretic peptide (BNP) concentrations in patients with a low ejection fraction undergoing isolated on-pump coronary artery bypass graft (CABG) surgery. A double-blind, randomized, controlled study. Modarres Hospital, Tehran, Islamic Republic of Iran. Sixty-six patients with a low ejection fraction who required coronary artery surgery were selected. Patients were allocated to a GIK (n = 36) or a control (n = 30) group. The GIK group received GIK solution (500 mL of dextrose in water (DW) 10% + 40 U of regular insulin + 40 mEq of KCl, and 2 g of MgSO(4)) at a rate of 1 mL/kg/h for 10 hours preoperatively and until the removal of the aortic cross-clamp. The control group received half saline solution as placebo with an equivalent infusion rate during the same interval. Serum NT-proBNP levels were measured before starting the GIK, at the time of anesthesia induction, and 24 hours after surgery. The primary outcome measures were preoperative and postoperative NT-proBNP level. The amount of elevation in postoperative NT-proBNP concentrations was less prominent in the GIK group than in the control group (2,601 ± 1,799 pg/mL v 4,732 ± 4,127 pg/mL; p = 0.02). The patients in the GIK group were extubated sooner (495 ± 92 minutes) than the control group (774 ± 224 minutes; p = 0.002). The overall extubation time was 606 ± 177 minutes. Delayed requirement for mechanical ventilation was significantly more in the controls compared with the GIK group (45.8% v 13.9%, p = 0.004). GIK is of value in the reduction of post-cardiac surgery NT-proBNP elevation. Thus, its infusion should have a protective effect in patients with low ejection fraction undergoing CABG surgery. Further studies may prove GIK infusion benefits in high-risk CABG surgery patients optimize outcome.

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: Impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: Impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

N-terminal pro B-type natriuretic peptide (NT pro-BNP) is a predictor of long-term survival in male patients of 75 years and older with high-grade asymptomatic internal carotid artery stenosis

Carotid endarterectomy (CEA) is commonly performed for asymptomatic high-grade internal carotid artery (ICA) stenosis to prevent stroke. However, despite advancing age of the society, for patients older than 75 years, there is no recommendation by the European guidelines for CEA, as this age group might not benefit from this intervention due to a limited life expectancy. We assessed N-terminal pro B-type natriuretic peptide (NT pro-BNP) as a predictive marker for long-term survival in this particular patient population in order to stratify patients for an improved surgical outcome. In a nonrandomized single-center clinical trial, we prospectively studied mortality rates of 205 consecutive patients (80 women, 125 men; mean age, 75 ± 10 years) with asymptomatic high-grade ICA stenosis in relation to preoperative plasma NT pro-BNP levels. We estimated cumulative survival over 5 years by Kaplan-Meier curves and established a proportional hazard-model by Cox regression. In male patients, higher levels of preoperative NT pro-BNP levels were associated with a significantly increased long-term mortality. Those 75 years or older had the same survival rate as younger patients, if NT pro-BNP levels were low, making them thus eligible for CEA. The results of our study suggest that preoperative plasma levels of NT pro-BNP are a valuable tool for the stratification of male patients. Male patients older than 75 years with low levels of NT pro-BNP should be referred for carotid revascularization, as they will most likely enjoy the benefit of surgery.

Düşük Ejeksiyon Fraksiyonlu Koroner Arter Baypas Greftleme Hastalarında Geç Dönem Sol Ventriküler Revers Remodeling ve Amino Terminal Pro-B-Tip Natriüretik Peptid

Objective: Left ventricular remodeling accelerates the course of cardiac failure by aggravating ventricular dysfunction following myocardial infarction. Thus, prediction and prevention of left ventricular remodeling is crucial. The aim of this study was to evaluate the predictive value of perioperative plasma NT-proBNP levels for postoperative left ventricular reverse remodeling and ejection fraction in patients who underwent coronary artery bypass grafting. Material and Methods: Forty patients with myocardial infarction inprevious three months were enrolled in the study. All patients with moderate left ventricular dysfunction (EF 40%) underwent on pump coronary artery bypass grafting (CABG) operation. Patients' preoperative left ventricle volumes and indexes, ejection fractions, and NT-proBNP levels were compared to the postoperative values. Results: Preoperative NT-proBNP levels were significantly related to preoperative and postoperative ejection fractions, and postoperative left ventricular reverse remodeling (p= 0.037, p= 0.033, p= 0.014, respectively). Conclusion: The preoperative N-terminal proBNP may help to assess the postoperative ejection fraction and ventricular remodeling. Amino terminal proBNP is a safe, available and effective tool to predict the postoperative functional and structural changes of the left ventricle.