Author + information
- Received May 11, 2018
- Revision received June 15, 2018
- Accepted July 23, 2018
- Published online November 5, 2018.
- Brian R. Lindman, MD, MSca,∗ (, )
- Marie-Annick Clavel, DVM, PhDb,
- Rami Abu-Alhayja'a, MDb,
- Nancy Côté, PhDb,
- François Dagenais, MDb,
- Eric Novak, MSc,
- Pierre Voisine, MDb,
- Anthony Poulin, MDb,
- Benoit J. Arsenault, PhDb,
- Philippe Desmeules, PhDb,
- Abdellaziz Dahou, MD, MSb,
- Lionel Taster, MScb,
- Khitam Aldahoun, RNb,
- Yohan Bossé, PhDb,
- Patrick Mathieu, MDb and
- Philippe Pibarot, DVM, PhDb
- aStructural Heart and Valve Center, Vanderbilt University School of Medicine, Nashville, Tennessee
- bQuebec Heart and Lung Institute, Quebec City, Canada
- cCardiovascular Division, Washington University School of Medicine, St. Louis, Missouri
- ↵∗Address for correspondence:
Dr. Brian R. Lindman, Structural Heart and Valve Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 300-A, Nashville, Tennessee 37203.
Objectives This study sought to evaluate whether a multimarker approach might identify patients with higher mortality and hospitalization rates after aortic valve replacement (AVR) for aortic stenosis (AS).
Background The society valve guidelines include accepted triggers for AVR in patients with severe asymptomatic AS, but circulating biomarkers do not have a clear role.
Method From a prospective registry of patients undergoing cardiac surgery between 2000 and 2012, 665 treated with surgical AVR (441 isolated) were evaluated. Seven biomarkers were measured on blood samples obtained before AVR. Biomarker levels were adjusted to account for the influence of age, sex, body mass index, and renal function; the median was used to determine an elevated value. Endpoints included all-cause mortality and all-cause and cardiovascular hospitalizations. Mean follow-up was 10.7 years and 299 (45%) died.
Results Patients with 0 to 1, 2 to 3, 4 to 6, and 7 biomarkers elevated had 5-year mortality of 10%, 12%, 24%, and 33%, respectively, and 10-year mortality of 24%, 35%, 58%, and 71%, respectively (log-rank p < 0.001). The association between an increasing number of elevated biomarkers and increased all-cause mortality was observed among those with minimal symptoms (New York Heart Association functional class I or II) and those with a low N-terminal pro–B-type natriuretic peptide (p < 0.01 for both). Compared with those with 0 to 1 biomarkers elevated, patients with 4 to 6 or 7 biomarkers elevated had an increased hazard of mortality after adjustment for clinical risk scores (p < 0.01) and a 2- to 3-fold higher rate of all-cause and cardiovascular rehospitalization after AVR. Similar findings were obtained when evaluating cardiovascular mortality. Among patients with no or minimal symptoms, 42% had ≥4 biomarkers elevated.
Conclusions Among patients with severe AS treated with surgical AVR, an increasing number of elevated biomarkers of cardiovascular stress was associated with higher all-cause and cardiovascular mortality and a higher rate of repeat hospitalization. A multimarker approach may be useful in the surveillance of asymptomatic patients with severe AS to optimize surgical timing.
- aortic valve stenosis
- risk stratification
- surgical aortic valve replacement
Dr. Lindman was supported by K23 HL116660. Dr. Pibarot was supported by research grant # FDN-143225 from the Canadian Institutes of Health Research. Dr. Pibarot is the Canada Research Chair in Valvular Heart Disease (Canadian Institutes of Health Research). Additional support was provided by a research grant from Roche Diagnostics. Dr. Lindman has served on the scientific advisory board for Roche Diagnostics; received research grants from Edwards Lifesciences and Roche Diagnostics; and served as a consultant for Medtronic. Dr. Novak is an employee of Gore & Associates, Inc. Dr. Pibarot has received research contracts from Edwards Lifesciences, Medtronic, and Roche Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 11, 2018.
- Revision received June 15, 2018.
- Accepted July 23, 2018.
- 2018 American College of Cardiology Foundation
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