This Article Full Text Full Text (PDF) All Versions of this Article: 115/22/2848    most recent CIRCULATIONAHA.106.654210v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bergler-Klein, J. Articles by Baumgartner, H. Search for Related Content PubMed PubMed Citation Articles by Bergler-Klein, J. Articles by Baumgartner, H. Pubmed/NCBI databases Compound via MeSH Substance via MeSH Related Collections Other heart failure Valvular heart disease CV surgery: valvular disease

(Circulation. 2007;115:2848-2855.)
© 2007 American Heart Association, Inc.

Valvular Heart Disease

B-Type Natriuretic Peptide in Low-Flow, Low-Gradient Aortic Stenosis

Relationship to Hemodynamics and Clinical Outcome: Results From the Multicenter Truly or Pseudo-Severe Aortic Stenosis (TOPAS) Study

Jutta Bergler-Klein, MD; Gerald Mundigler, MD; Philippe Pibarot, DVM, PhD; Ian G. Burwash, MD; Jean G. Dumesnil, MD; Claudia Blais, MSc; Christina Fuchs, MD; Dania Mohty, MD, MSc; Rob S. Beanlands, MD; Zeineb Hachicha, MD; Nicole Walter-Publig, MD; Florian Rader, MD; Helmut Baumgartner, MD

From the Department of Cardiology (J.B.-K., G.M., C.F., N.W.-P., F.R., H.B.), Medical University of Vienna, Vienna, Austria; Laval Hospital/Quebec Heart Institute (P.P., J.G.D., C.B., D.M., Z.H.), Laval University, Sainte-Foy, Quebec, Canada; and the University of Ottawa Heart Institute (I.G.B, R.S.B), Ottawa, Ontario, Canada.

Correspondence to Jutta Bergler-Klein, MD, Department of Cardiology, Medical University of Vienna, Waehringer-Guertel 18-20, A-1090 Vienna, Austria. E-mail jutta.bergler-klein{at}meduniwien.ac.at

Received August 11, 2006; accepted March 19, 2007.

Background— The prognostic value of B-type natriuretic peptide (BNP) is unknown in low-flow, low-gradient aortic stenosis (AS). We sought to evaluate the relationship between AS and rest, stress hemodynamics, and clinical outcome.

Methods and Results— BNP was measured in 69 patients with low-flow AS (indexed effective orifice area <0.6 cm²/m², mean gradient 40 mm Hg, left ventricular ejection fraction 40%). All patients underwent dobutamine stress echocardiography and were classified as truly severe or pseudosevere AS by their projected effective orifice area at normal flow rate of 250 mL/s (effective orifice area 1.0 cm² or >1.0 cm²). BNP was inversely related to ejection fraction at rest (Spearman correlation coefficient r_s=–0.59, P<0.0001) and at peak stress (r_s=–0.51, P<0.0001), effective orifice area at rest (r_s=–0.50, P<0.0001) and at peak stress (r_s=–0.46, P=0.0002), and mean transvalvular flow (r_s=–0.31, P=0.01). BNP was directly related to valvular resistance (r_s=0.42, P=0.0006) and wall motion score index (r_s=0.36, P=0.004). BNP was higher in 29 patients with truly severe AS versus 40 with pseudosevere AS (median, 743 pg/mL [Q1, 471; Q3, 1356] versus 394 pg/mL [Q1, 191 to Q3, 906], P=0.012). BNP was a strong predictor of outcome. In the total cohort, cumulative 1-year survival of patients with BNP 550 pg/mL was only 47±9% versus 97±3% with BNP <550 (P<0.0001). In 29 patients who underwent valve replacement, postoperative 1-year survival was also markedly lower in patients with BNP 550 pg/mL (53±13% versus 92±7%).

Conclusions— BNP is significantly higher in truly severe than pseudosevere low-gradient AS and predicts survival of the whole cohort and in patients undergoing valve replacement.

---

 

CLINICAL PERSPECTIVE

This article has been cited by other articles:

				P. Lancellotti, C. Szymanski, M. Moonen, C. Garweg, K. O'Connor, C. Tribouilloy, and L. A. Pierard Dynamic left ventricular dyssynchrony: a potential cause of no contractile reserve in patients with low-gradient aortic stenosis Eur J Echocardiogr, October 1, 2009; 10(7): 880 - 883. [Abstract] [Full Text] [PDF]

				F. Weidemann, S. Herrmann, S. Stork, M. Niemann, S. Frantz, V. Lange, M. Beer, S. Gattenlohner, W. Voelker, G. Ertl, et al. Impact of Myocardial Fibrosis in Patients With Symptomatic Severe Aortic Stenosis Circulation, August 18, 2009; 120(7): 577 - 584. [Abstract] [Full Text] [PDF]

				E. E. Coglianese and R. Davidoff Predicting Outcome in Patients With Asymptomatic Aortic Stenosis Circulation, July 7, 2009; 120(1): 9 - 11. [Full Text] [PDF]

				C. Tribouilloy, F. Levy, D. Rusinaru, P. Gueret, H. Petit-Eisenmann, S. Baleynaud, Y. Jobic, C. Adams, B. Lelong, A. Pasquet, et al. Outcome After Aortic Valve Replacement for Low-Flow/Low-Gradient Aortic Stenosis Without Contractile Reserve on Dobutamine Stress Echocardiography J. Am. Coll. Cardiol., May 19, 2009; 53(20): 1865 - 1873. [Abstract] [Full Text] [PDF]

				R. W. Troughton and A. M. Richards B-type natriuretic peptides and echocardiographic measures of cardiac structure and function. J. Am. Coll. Cardiol. Img., February 1, 2009; 2(2): 216 - 225. [Abstract] [Full Text] [PDF]

				C. Tribouilloy and F. Levy Assessment and management of low-gradient, low ejection fraction aortic stenosis Heart, December 1, 2008; 94(12): 1526 - 1527. [Full Text] [PDF]

				J. P. Dal-Bianco, B. K. Khandheria, F. Mookadam, F. Gentile, and P. P. Sengupta Management of Asymptomatic Severe Aortic Stenosis J. Am. Coll. Cardiol., October 14, 2008; 52(16): 1279 - 1292. [Abstract] [Full Text] [PDF]

				M.-A. Clavel, C. Fuchs, I. G. Burwash, G. Mundigler, J. G. Dumesnil, H. Baumgartner, J. Bergler-Klein, R. S. Beanlands, P. Mathieu, J. Magne, et al. Predictors of Outcomes in Low-Flow, Low-Gradient Aortic Stenosis: Results of the Multicenter TOPAS Study Circulation, September 30, 2008; 118(14_suppl_1): S234 - S242. [Abstract] [Full Text] [PDF]

				H. Subramanian, B. Kunadian, and J. Dunning Is it ever worth contemplating an aortic valve replacement on patients with low gradient severe aortic stenosis but poor left ventricular function with no contractile reserve? Interactive CardioVascular and Thoracic Surgery, April 1, 2008; 7(2): 301 - 305. [Abstract] [Full Text] [PDF]

				B. A. Carabello Aortic Stenosis: Two Steps Forward, One Step Back Circulation, June 5, 2007; 115(22): 2799 - 2800. [Full Text] [PDF]