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Acute Heart Failure at the Time of Transcatheter Aortic Valve Replacement Does Not Increase Mortality
Insights
Transcatheter aortic valve replacement is safe for patients with acute on chronic heart failure, even with high N-terminal pro-B-type natriuretic peptide levels. Elevated N-terminal pro-B-type natriuretic peptide only increased intensive care unit stay, not mortality.
Area of Science:
- Cardiology
- Cardiac Surgery
- Heart Failure Management
Background:
- Patients undergoing transcatheter aortic valve replacement (TAVR) often present with acute on chronic heart failure, indicated by elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP).
- A common clinical belief is to medically manage elevated NT-proBNP, delaying TAVR until patients are medically optimized.
Purpose of the Study:
- To evaluate the safety and outcomes of TAVR in patients with elevated preoperative NT-proBNP levels.
- To determine if high NT-proBNP is a contraindication for TAVR or necessitates medical optimization prior to the procedure.
Main Methods:
- A single-center TAVR database was queried from December 2015 to November 2016.
- Patients were stratified into two cohorts based on preoperative NT-proBNP levels (<3000 pg/mL vs. >3000 pg/mL).
- Outcomes assessed included ICU length of stay, total length of stay, discharge disposition, major complications, and 30-day mortality.
Main Results:
- 142 patients (median age 80) were analyzed; 32% had NT-proBNP >3000 pg/mL.
- Elevated NT-proBNP (>3000 pg/mL) was associated with a significantly longer ICU stay (>24 hours; 35% vs. 9%, P=0.0001).
- No significant differences were observed in total length of stay, discharge to home, major complications, or 30-day mortality between cohorts.
Conclusions:
- TAVR is an appropriate and effective treatment for patients with aortic stenosis and elevated NT-proBNP, indicative of acute on chronic heart failure.
- High preoperative NT-proBNP levels should not preclude patients from undergoing TAVR, as it does not negatively impact major adverse outcomes.
- The findings support proceeding with TAVR in selected patients regardless of NT-proBNP levels, challenging the notion of mandatory medical optimization.
Objective:
Patients presenting for transcatheter aortic valve replacement are often in acute on chronic heart failure, as indicated by elevated N-terminal pro-B-type natriuretic peptide. Many believe that elevated N-terminal pro-B-type natriuretic peptide is an indication to treat medically, reserving surgery until the patient is medically optimized.
Methods:
A single-center transcatheter aortic valve replacement database was queried from December 2015 to November 2016 to identify patients undergoing transcatheter aortic valve replacement. Patients were divided into two cohorts based on preoperative N-terminal pro-B-type natriuretic peptide level. An analysis was then completed to assess outcomes such as length of intensive care unit stay, total length of stay, discharge to home, major complications, and mortality at 30 days.
Results:
There were 142 patients (median age = 80 years, 44% female) with preoperative N-terminal pro-B-type natriuretic peptide data included (range = 106-73,500 pg/mL). The mean Society of Thoracic Surgeons predicative risk of mortality was 8%, and 46 patients (32%) had N-terminal pro-B-type natriuretic peptide of greater than 3000 pg/mL. N-terminal pro-B-type natriuretic peptide of greater than 3000 pg/mL was associated only with increased intensive care unit length of stay of greater than 24 hours (35% vs 9%, P = 0.0001). There was no statistical difference between cohorts with regard to total length of stay of greater than 3 days (24% vs 15%, P = 0.2), discharge to home (74% vs 83%, P = 0.3), major complication, or mortality at 30 days.
Conclusions:
Transcatheter aortic valve replacement is an appropriate and effective treatment for patients with aortic stenosis presenting with high N-terminal pro-B-type natriuretic peptide and acute on chronic heart failure.
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