Informação da revista
Vol. 37. Núm. 1.Janeiro 2018
Páginas e1-e2Páginas 1-96
Baixar PDF
Mais opções do artigo
Vol. 37. Núm. 1.Janeiro 2018
Páginas e1-e2Páginas 1-96
Editorial comment
DOI: 10.1016/j.repc.2018.01.003
Open Access
How to predict futility: The holy grail of transcatheter aortic valve implantation
Como prever a futilidade? O santo graal da implantação percutânea de válvulas aórticas
Tiago Rodriguesa,b,c, Eduardo Infante de Oliveiraa,b,c,
Autor para correspondência

Corresponding author.
a Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
b Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
c Centro Académico de Medicina de Lisboa, Lisboa, Portugal
Conteúdo relacionado
Rev Port Cardiol 2018;37:67-7310.1016/j.repc.2017.06.016
Nelson Carlos Vale, Rui Campante Teles, Sérgio Madeira, João Brito, Manuel Sousa Almeida, Tiago Nolasco, Joao Abecasis, Gustavo Rodrigues, João Carmo, Maria Furstenau, Regina Ribeiras, José Pedro Neves, Miguel Mendes
Este item recebeu

Under a Creative Commons license
Informação do artigo
Texto Completo
Baixar PDF
Texto Completo

Transcatheter aortic valve implantation (TAVI) is currently the gold standard for the treatment of severe aortic stenosis in patients with high risk or contraindication for open heart surgery. However, a considerable proportion of patients do not benefit from TAVI, either dying or failing to improve. Markers of prognosis and futility have been extensively investigated, and frailty and clinical risk scores are the cornerstone of prognosis assessment.1 Nonetheless, substantial research remains to be done in order to arrive at an accurate and meaningful prognosis with a limited number of parameters that can be easily collected during clinical practice.1 Biomarkers are generally not included in these scores, even though their potential independent predictive value has been documented.2 Various biomarkers have been explored in the particular setting of aortic stenosis treated by TAVI. A recent systematic review elegantly presented the most important evidence regarding the predictive value of B-type natriuretic peptide (BNP), troponin, cancer antigen 125, red cell distribution width, growth differentiation factor, malonaldehyde, galectin-3, soluble ST2 and von Willebrand factor.2

BNP and its prohormone N-terminal proBNP (NT-proBNP) have considerable prognostic value in patients with heart failure and valvular heart disease.3,4 Natriuretic peptides correlate with aortic stenosis severity and area, peak velocity and gradient, other echocardiographic markers of high risk, and prognosis.4,5 In some studies, the confounding effect of reduced left ventricular function and concomitant valvulopathies has been effectively excluded.6,7 According to the most recent guidelines by the joint task force of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), serum BNP levels are related to New York Heart Association (NYHA) functional class and prognosis in aortic stenosis and may be of value for risk stratification and timing of intervention, particularly in asymptomatic patients.8 The prognostic value of BNP in the specific setting of TAVI has also been addressed by several authors. There are disparities regarding the recommended timing for assessing BNP levels, with some authors reporting that baseline BNP is independently associated with mortality, while others state that variation, particularly an increase, from baseline is the most informative and predictive parameter. Abramowitz et al. reported a series of 780 patients in which baseline BNP levels were associated with increased short- and medium-term mortality after TAVI.9 A recent meta-analysis by Giordana et al., including 25 studies and almost 9000 patients, concluded that high preprocedural BNP levels were a strong independent predictor of both 30-day and one-year mortality.10 These findings imply that elevated baseline BNP may reflect irreversible loss of ventricular reserve and could play a role as a marker of futility. On the other hand, Koshinas et al., in a study of 219 patients with serial measurements of BNP and NT-proBNP before and after intervention, found that outcomes were most unfavorable in patients with persistently high BNP both before and after the intervention. Comparing the two biomarkers, NT-proBNP levels measured after TAVI showed the highest prognostic discrimination for two-year mortality. Baseline-to-discharge reduction, but not baseline BNP levels, were related to functional improvement (NYHA class).11 In the PARTNER trial,12 baseline and 30-day BNP levels were assessed in 933 patients who underwent TAVI via transfemoral access. An increase in BNP at 30 days from baseline was independently associated with one-year mortality.12 The OCEAN-TAVI multicenter prospective registry, with 1094 patients, also suggests that an elevation of BNP (>202 pg/ml) at discharge is associated with two-year mortality and hospitalization after TAVI.13 A time-dependent net reclassification improvement and integrated discrimination improvement analysis revealed that incorporation of BNP stratification with other clinical variables significantly improved predictive accuracy for two-year mortality.13 However, the authors did not explore the value of baseline BNP levels or the value of the difference or ratio between pre- and post-intervention levels.

In the current issue of the Journal, Vale et al.14 present an interesting single-center retrospective analysis of 151 patients undergoing TAVI in whom both baseline and one-month post-procedure NT-proBNP were measured. Receiver operating characteristic curve analysis was used to identify the best discriminative values for one-year mortality. Independent predictors of one-year mortality were assessed by Cox regression. Only post-procedural NT-proBNP (>2500 pg/ml, area under the curve 0.72) was independently and negatively associated with one-year survival (hazard ratio 5.9, 95% confidence interval 1.6-21.7, p=0.008). Baseline NT-proBNP and the difference and the ratio between NT-proBNP pre- and post-procedure did not predict one-year mortality. A major limitation derives from the fact that collection of post-procedural NT-proBNP was not possible for patients who died in the first month, who were therefore not included in the protocol. Nevertheless, this paper also suggests that pre-procedural natriuretic peptide levels may have a limited role in assessing prognosis and futility. Post-procedural myocardial response, and the subsequent reset of natriuretic peptide levels, appear to be more useful for determining prognosis and identifying high-risk patients who will require closer and optimized follow-up. However, this high-value information is only available after making the commitment to perform TAVI.

A famous Portuguese soccer player, João Domingos da Silva Pinto, was once asked to predict the result of an important match. His answer became part of our national heritage: “Prognostics only after the game.” This is exactly what natriuretic peptides seem to be able to offer for TAVI. Unfortunately, biomarkers are still unable to help us to avoid futility.

Conflicts of interest

The authors have no conflicts of interest to declare.

R. Puri,B. Iung,D.J. Cohen
TAVI or No TAVI: identifying patients unlikely to benefit from transcatheter aortic valve implantation
Eur Heart J, 37 (2016), pp. 2217-2225
B. Redfors,A. Furer,B.R. Lindman
Biomarkers in aortic stenosis: a systematic review
Struct Hear, 1 (2017), pp. 18-30
P. Jourdain,G. Jondeau,F. Funck
Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure
J Am Coll Cardiol, 49 (2007), pp. 1733-1739
C.D. Steadman,S. Ray,L.L. Ng
Natriuretic peptides in common valvular heart disease
J Am Coll Cardiol, 55 (2010), pp. 2034-2048
M. Weber,R. Arnold,M. Rau
Relation of N-terminal pro-B-type natriuretic peptide to severity of valvular aortic stenosis
Am J Cardiol, 94 (2004), pp. 740-745
N. Farré,M. Gómez,L. Molina
Prognostic value of NT-proBNP and an adapted monin score in patients with asymptomatic aortic stenosis
Rev Esp Cardiol (Engl Ed), 67 (2014), pp. 52-57
R. Capoulade,J. Magne,R. Dulgheru
Prognostic value of plasma B-type natriuretic peptide levels after exercise in patients with severe asymptomatic aortic stenosis
H. Baumgartner,V. Falk,J.J. Bax
2017 ESC/EACTS guidelines for the management of valvular heart disease
Eur Heart J, 38 (2017), pp. 2739-2791
Y. Abramowitz,T. Chakravarty,H. Jilaihawi
Impact of preprocedural B-type natriuretic peptide levels on the outcomes after transcatheter aortic valve implantation
Am J Cardiol, 116 (2015), pp. 1904-1909
F. Giordana,F. D’Ascenzo,F. Nijhoff
Meta-analysis of predictors of all-cause mortality after transcatheter aortic valve implantation
Am J Cardiol, 114 (2014), pp. 1447-1455
K.C. Koskinas,C.J. O'Sullivan,D. Heg
Effect of B-type natriuretic peptides on long-term outcomes after transcatheter aortic valve implantation
Am J Cardiol, 116 (2015), pp. 1560-1565
B.P. O’Neill,M. Guerrero,V.H. Thourani
Prognostic value of serial B-type natriuretic peptide measurement in transcatheter aortic valve replacement (from the PARTNER Trial)
Am J Cardiol, 115 (2015), pp. 1265-1272
K. Mizutani,M. Hara,S. Iwata
Elevation of B-type natriuretic peptide at discharge is associated with 2-year mortality after transcatheter aortic valve replacement in patients with severe aortic stenosis: insights from a Multicenter Prospective OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) Registry
J Am Heart Assoc, 6 (2017), pp. e006112
N.C. Vale,R.C. Teles,S. Madeira
Post-procedural N-terminal brain natriuretic peptide predicts one-year mortality after transcatheter aortic valve implantation
Rev Port Cardiol, 37 (2018), pp. 67-73
Copyright © 2018. Sociedade Portuguesa de Cardiologia
Revista Portuguesa de Cardiologia

Receba a nossa Newsletter

Opções de artigo
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos