Relation of N-terminal pro B-type natriuretic peptide to progression of aortic valve disease.

AIMS: Recently an elevation of B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) in patients with aortic stenosis (AS) and aortic regurgitation (AR) has been described. The objective of this study was to evaluate the relation of NT-proBNP values to the progression of aortic valve disease. METHODS AND RESULTS: One hundred and sixty-eight patients were included. NT-proBNP was elevated in patients with AS (n=109) and AR (n=37) linked to disease severity. Values for NT-proBNP, pressure gradient, and left ventricular mass were identical in patients (n=22) after previous valve replacement and in those patients with mild AS. NT-proBNP levels decreased in 86 patients after valve replacement (2292+/-353 vs. 785+/-101 pg/ml; P<0.01) but increased in 82 patients who were treated conservatively (616+/-120 vs. 1155+/-432 pg/mL; P=0.029), related to the progression of disease. CONCLUSION: NT-proBNP is elevated in patients with aortic valve disease linked to disease severity and decreases after successful surgical therapy but increases in conservatively treated patients. These data underline the consistent relation of NT-proBNP to severity of aortic valve disease. Therefore, NT-proBNP should be considered as a biomarker for the monitoring of disease during follow-up, but further studies are warranted.     

钙化性主动脉瓣狭窄的外科治疗

目的评价钙化性主动脉瓣狭窄外科治疗效果及成功因素。方法对26例钙化性主动脉瓣狭窄患者随访分析,年龄55～70岁,平均62岁。主动脉跨瓣压差52～191mmHg,平均97mmHg,室间隔、左室后壁厚度14～19mm,合并关闭不全7例。手术均在全麻、低温和体外循环下行机械瓣置换,同期行Manouguian法扩大主动脉瓣环9例、CABG3例、Wheat术1例。结果术后早期和晚期各死亡1例。随访心脏超声LVEF为51%～72%,室间隔及左室后壁厚度8～12mm,人工瓣跨瓣压差8～26mmHg。心功能为Ⅰ～Ⅱ级。结论瓣膜置换是治疗钙化性主动脉瓣狭窄唯一安全有效的方法,恰当的手术时机、合适的瓣膜型号是提高手术远期疗效的重要保证。     

老年人主动脉瓣置换术后病死率分析

目的 对年龄≥70岁的主动脉瓣狭窄患者主动脉瓣置换术后的病死率进行分析.方法 回顾性分析246例年龄≥70岁、并接受主动脉瓣置换的主动脉瓣狭窄患者的临床资料.其中高血压144例(58.5%),心房颤动42例(17.1%),肥胖27例(11.0%),有心脏手术史18例(7.3%).结果 手术30 d内死亡29例,病死率为...     

N末端B型利钠肽原对单纯主动脉瓣狭窄心力衰竭患者的诊断价值

目的 评价N末端B型利钠肽原(NT-proBNP)对单纯主动脉瓣狭窄(AS)心力衰竭(心衰)患者的诊断价值.方法 使用酶联免疫的方法对40例AS心衰患者(AS心衰组)和76例正常对照者(正常组)行NT-pmBNP测定,评价其对AS心衰的诊断价值.结果 与正常组相比,AS心衰组NT-proBNP水平显著增高(P<0.01)且在纽约心功能分级(NYHA分级)Ⅱ、Ⅲ和Ⅳ级者呈逐级显著升高(均为P<0.01);其中,临床代偿心衰差异无统计学意义(P>0.05),而临床失代偿心衰升高8倍(P<0.01);在左室舒张期末内径(LVEDD)>50 mm组显著高于LVEDD≤50mm组(P<0.05),左室射血分数(LVEF)≤60%组显著高于LVEF>60%组(P<0.01);在合并心房颤动组显著高于窦性心律组(P<0.05).NT-pmBNP阈值在1360 ng/L时,是诊断心衰(ROC曲线下面积=0.762,P<0.01)及失代偿心衰(ROC曲线下面积=0.997,P<0.01)的最佳阈值;心衰与失代偿心衰诊断的敏感性分别为67.50%和100.00%,特异性均为96.05%,准确性分别为86.21%和95.83%.单因素和多元逐步回归分析一致显示,Log(NT-proBNP)与NYHA分级和LVEF呈显著正、负相关(P<0.05),且呈独立相关.结论 NT-pwBNP对单纯As心衰患者也有重要诊断价值.建议临床采用1360 ng/L作为阈值,诊断单纯AS伴心衰者准确性高达86.21%,尤其对失代偿者准确性高达95.83%.     

Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?

AIMS: In aortic stenosis (AS), left ventricular (LV) hypertrophy is considered a compensatory response helping maintain systolic function. Recent research in experimental AS suggests, however, that LV hypertrophy is not necessary to sustain LV contractions but may in fact be maladaptive. The present work aimed to clarify the role of LV hypertrophy in AS-related heart failure (HF) in man. METHODS AND RESULTS: We studied 137 adult patients with isolated AS undergoing pre-operative echocardiography and cardiac catheterization. HF was diagnosed by the European criteria and LV hypertrophy by sex-specific limits of echocardiographic LV mass. The higher the LV mass was, the poorer was the LV ejection fraction (beta=-0.26, P< 0.001, linear regression) and the greater the likelihood of HF independent of the severity of AS (P< 0.001, logistic regression). In the subgroup of critical AS (valve area <0.4 cm(2)/m(2), n=85), patients with absent LV hypertrophy (n=19) had better preserved ejection fraction (mean+/-SE, 64+/-3 vs. 57+/-2%, P=0.045) and less HF (16 vs. 48%, P=0.025) than patients with LV hypertrophy (n=66). CONCLUSION: In isolated AS, increased LV mass predicts the presence of systolic dysfunction and HF independent of the severity of valvular obstruction. LV hypertrophy may be maladaptive rather than beneficial in AS in man.     

Diagnosing heart failure in aortic valve stenosis

OBJECTIVE: In aortic valve stenosis (AS), heart failure (HF) omens a high risk of death and is an indication for prompt valve replacement. We studied whether its detection can be facilitated by measuring plasma N-terminal B-type natriuretic peptide (Nt-BNP) or by estimating pulmonary capillary wedge pressure (PCWP) using echocardiography. DESIGN AND SETTING: A cross-sectional cohort study in a university hospital. SUBJECTS AND METHODS: We studied 137 consecutive adult patients referred to our unit for invasive evaluation of isolated AS. All patients underwent cardiac catheterization, measurement of plasma Nt-BNP and estimation of PCWP by Doppler echocardiography of transmitral and pulmonary venous flow velocities. The final diagnosis of HF was based on the combined criteria of dyspnoea on ordinary effort and PCWP >14 mmHg at cardiac catheterization. The performance of Nt-BNP and the PCWP estimate in the detection of HF were studied using receiver operating characteristic (ROC) analysis. RESULTS: Totally 42 patients had HF. A cardiologist's clinical diagnosis of HF had high specificity (94%) but poor sensitivity (66%). With an optimized cut-off point, plasma Nt-BNP had moderate sensitivity (77%) and specificity (79%) for HF; the ROC area was 0.83. The echocardiographic PCWP estimate classified 90% of patients correctly as having normal or truly elevated (>14 mmHg) PCWP. Its sensitivity and specificity for the diagnosis of HF were 80 and 95% respectively; the ROC area was 0.88. With a cut-off point of 12 mmHg, the sensitivity of the PCWP estimate was 85% and specificity, 88%. CONCLUSION: The recognition of HF in patients with AS can be improved by estimating PCWP using Doppler echocardiography of transmitral and pulmonary venous flow velocities.     

The diagnostic utility of N-terminal pro-B-type natriuretic peptide for the detection of major structural heart disease in patients with atrial fibrillation.

AIMS: To assess the role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the diagnosis of major structural heart disease (MSHD) in patients with atrial fibrillation (AF) compared with those with sinus rhythm (SR) using receiver operator characteristic (ROC) analysis. NT-proBNP is elevated in MSHD and heart failure (HF). AF, a common finding in HF and MSHD, is also associated with raised plasma NT-proBNP. As a result, the utility of NT-proBNP for predicting MSHD may be reduced. METHODS AND RESULTS: One thousand four hundred and seventy-six patients underwent assessment at a single centre, performed without the knowledge of NT-proBNP levels. MSHD included left ventricular (LV) systolic and diastolic dysfunctions, left-sided valvular disease, right heart disease (including pulmonary hypertension) and severe LV hypertrophy. One hundred and fifty-five patients were excluded due to renal impairment, atrial flutter, or a pacemaker. Seven hundred and ninety-three patients were diagnosed with MSHD. Median NT-proBNP concentrations for patients with MSHD were 960 (IQR 359-2625) pg/mL and 2491 (1443-4368) pg/mL for SR (n = 591) and AF (n = 202), respectively (P < 0.001). Patients without MSHD had NT-proBNP levels of 179 (90-401) pg/mL and 1000 (659-1760) pg/mL for SR (n = 454) and AF (n = 74), respectively (P < 0.001). The area under the ROC curve for NT-proBNP to detect MSHD was 0.79 for SR (95% CI 0.77-0.82) and 0.78 for AF (95% CI 0.72-0.84). NT-proBNP cut-off levels necessary to achieve a 1 in 100 false negative rate were 27.5 (7.5-30.5) pg/ml and 524 (253-662) pg/ml for SR and AF, respectively. CONCLUSION: NT-proBNP performs as well in patients with SR as in those with AF. However, significantly higher cut-off levels are required for patients with AF to achieve similar levels of diagnostic specificity.     

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.     

Diagnostic value of a rapid test for B-type natriuretic peptide in patients presenting with acute dyspnoe: effect of age and gender

BACKGROUND: B-type natriuretic peptide (BNP) measurements are useful for diagnosing congestive heart failure (CHF) in patients presenting to the Emergency Department with acute dyspnoe. Whether the diagnostic accuracy of BNP is affected by the age and gender of the patients remains unknown. AIMS: To evaluate the accuracy of BNP testing for diagnosing CHF in an unselected group of patients admitted to the emergency department of a Norwegian teaching hospital with a principal complaint of shortness of breath and to assess whether the diagnostic accuracy of the test differs according to age and gender. METHODS: BNP levels in plasma were determined by a point-of-care device upon arrival in 155 patients presenting with acute dyspnoe. The diagnostic 'gold' standard for CHF was adjudicated by two independent cardiologists who were blinded to the BNP data. RESULTS: By univariate logistic regression analysis, BNP was strongly related to a diagnosis of CHF. In a multivariate model BNP provided additional prognostic information to patient age and gender, radiographic evidence of pulmonary congestion and cardiomegaly, and the presence of pulmonary rales and jugular vein distention by physical examination. There was no significant interaction between age and BNP or between gender and BNP with regard to the accuracy of diagnosing CHF. The area under the receiver-operating characteristics-curve was 0.86 (95% confidence interval 0.78-0.93) in women and 0.90 (0.82-0.97) in men. The area under the curves were 0.82 (0.73-0.92) and 0.88 (0.80-0.97) for patients (both genders) aged > or = 76 and <76 years, respectively. CONCLUSION: Point-of-care BNP measurement in the emergency department discriminates well between patients with dyspnoe of cardiac and non-cardiac origin regardless of age and gender.     

Diagnosis and management of aortic valve stenosis in patients with heart failure

Aortic stenosis (AS) is the most frequent degenerative valvular heart disease in Western countries and its prevalence increases in parallel with the ageing process of the population. Heart failure (HF), defined by the presence of reduced left ventricular ejection fraction, may be present in up to a quarter of patients with severe AS, posing diagnostic and management challenges. The present article reviews the prevalence of HF in severe AS patients, discusses the diagnostic challenges and the advances in multimodality imaging to identify the patients that may benefit from surgical or transcatheter aortic valve replacement, and summarizes the current evidence on management for this group of patients.     

先天性主动脉瓣病变感染性心内膜炎的瓣膜置换术

目的　探讨先天性主动脉瓣病变继发感染性心内膜炎 (CAVE)的外科治疗。方法1990年 5月 1999年 8月间共收治 5 2例CAVE。男 37例 ,女 15例 ,平均年龄 33 3岁。平均心胸比率为 0 5 8,左室舒张末径为 5 3～ 94mm (平均 6 8mm)。瓣膜病理类型以主动脉二瓣化畸形为主 ,占6 8%。术前血培养阳性率为 36 4 %。超声心动图检查结合术后病理检查是诊断CAVE的主要方法。瓣膜赘生物阳性率为 80 8%。心功能 (NYHA)Ⅲ级 2 8例 ,IV级 11例。全组病例均在体外循环下行主动脉瓣置换术 ,均选用机械瓣 (St Jude和Medtronic Hall占 6 0 % )。结果　早期死亡 2例 ,1例死于脑栓塞 ,1例死于 2次瓣膜置换术后瓣周漏严重心功能衰竭。 2例完全性房室传导阻滞均安装永久性心脏起搏器。出院检查体温均正常。平均左室舒张末径为 5 5mm (P <0 0 1)。随访 4 6例 ,平均随访 38个月。 1例术后发生瓣膜功能障碍。无晚期死亡和心内膜炎复发。结论　强调对CAVE早期治疗。术中彻底清除感染病灶 ,结合术后有效抗生素的应用 ,是防止术后心内膜炎复发的关键     

Pre-discharge B-type natriuretic peptide predicts early recurrence of decompensated heart failure in patients admitted to a general medical unit

BACKGROUND: B-type natriuretic peptide (BNP) represents a promising predictor of early (30 days) re-admission in patients with heart failure (HF) admitted to cardiology units. Whether BNP retains its predictive value in unselected patients admitted to general medical wards is unknown. METHODS: We determined BNP levels on admission and pre-discharge in 100 consecutive patients (71 male, mean age 78+/-10 years) admitted to a general medical unit due to decompensated HF. Follow-up after discharge was 30 days. RESULTS: Of the 100 patients, 86 had >/=1 comorbid conditions. Median BNP was 739 pg/ml on admission (25th-75th percentile 355-1333 pg/ml, respectively), and 414 pg/ml pre-discharge (25th-75th percentile 220-696 pg/ml). Seventeen patients were re-admitted or died within 30 days. Patients with pre-discharge BNP values >75th percentile (696 pg/ml) had greater risk of re-hospitalisation, as compared to values 75th percentile were associated with a 15.0 independent relative hazard (RH) of early re-admission or death (95% CI 4.2-53.8; p<0.0001). The other independent predictor was a NYHA class >/=III at discharge (RH 2.9; 95% CI 1.1-9.3; p<0.05). CONCLUSION: In a general medical unit, pre-discharge BNP levels were a strong independent predictor of early re-admission or death due to HF, irrespective of substantial comorbidity and advanced age.     

老年心力衰竭患者血浆脑钠肽与N末端B型钠尿肽影响因素的探讨

目的 探讨老年心力衰竭患者血浆脑钠肽(BNP)和N末端B型钠尿肽(NT-proBNP)水平与心力衰竭严重程度、左心室功能等因素的关系,以及肾功能对BNP和NT-proBNP值的影响.方法采用免疫荧光分析法测定106例住院心力衰竭患者BNP水平,采用电化学发光免疫分析法测定48例住院心力衰竭患者NT-proBNP水平.均用心脏彩色多普勒超声诊断仪测定左心室收缩功能,心力衰竭按纽约分级(NYHA). 结果 BNP≤400 ng/L和>400 ng/L患者,左心射血分数(EF)值<45.0%者分别为16.4%和46.8%(χ~2=13.93,P=0.001);心脏彩超A峰、E峰流速比值(E/A)<1者分别为62.3%和40.4%,(χ~2-22.19,P=0.024);肌酐>107 μmol/L者分别为13.1%和38.3%(χ~2=11.31,P=0.002).NT-proBNP≤1800 ng/L和>1800 ng/L患者,EF值<45%者分别为25.0%和58.3%,(χ~2=10.00,P=0.019);E/A≤1者分别为70.1%和20.8%;肌酐>107μmol/L分别为20.8%,和50.0%(χ~2=8.50,P=0.035). 结论 老年心力衰竭患者血浆BNP及NT-proBNP水平随着心力衰竭严重程度的增加而升高,并能较好反映左室功能;肾脏功能对BNP及NT-proBNP水均有影响.     

Post-procedural N-terminal pro-brain natriuretic peptide predicts one-year mortality after transcatheter aortic valve implantation

Introduction

Natriuretic peptides are ubiquitously used for diagnosis, follow-up and prognostic assessment in various heart conditions. N-terminal pro-brain natriuretic peptide (NT-proBNP) correlates with aortic stenosis severity, however its significance after transcatheter aortic valve implantation (TAVI) is not well established.

心力衰竭患者B型利钠肽的测定与评价

目的:研究B型利钠肽(BNP)在心力衰竭诊断中的应用。方法:采用双抗夹心免疫荧光法检测342例患者的BNP浓度。其中充血性心衰(CHF,心源性)组179例,肺源性心衰组27例,无心衰的对照组136例。结果:(1)在无心衰对照组中,年龄小于55岁组的心源性浓度均值为(35.10±31.93)pg/ml,55～64岁组为(42.85±34.55)pg/ml,65～74岁组为(58.23±25.37)pg/ml,≥75岁组为(60.66±48.95)pg/ml,各组间BNP浓度均值虽随年龄呈上升趋势但无显著差异;(2)对照组中男性BNP浓度为(42.83±38.01)pg/ml,女性为(49.47±48.14)pg/ml,两者无显著差异;(3)在342例患者中BNP以100pg/ml为CHF的判断值时,其敏感性达92.8%,特异性达83.2%,阳性预测值达86.2%,阴性预测值达91.2%;(4)CHF(心源性)患者的BNP浓度均值为(1019.13±972.88)pg/ml,肺源性心衰组为(299.88±275.5)pg/ml,对照组为(45.86±42.89)pg/ml,CHF(心源性)组BNP水平显著高于其他两组,肺源性心衰组又显著高于对照组(P均<0.001)。结论:BNP测定不仅可以作为CHF诊断的一个重要指标,还可用于参考性区分心源性心衰和肺源性心衰,为选择治疗方案提供依据。     

Noninvasive quantification of the aortic valve area in aortic stenosis by Doppler echocardiography

To develop a noninvasive approach to the quantification of thestenotic aortic valve area, Doppler echocardiography and cardiaccatheterisation were performed in 24 patients with pure aorticstenosis. The transmitral volumetric flow was measured by Dopplerechocardiography and calculated as the product of the correctedmitral orifice area (CM A) and the diastolic velocity integral(DVI). The maximal aortic jet velocities were recorded by Dopplertechnique and integrated to obtain the systolic velocity integral(SVl). Assuming that the aortic and mitral volumetric flowsare equal, the aortic valve area (A VA) was calculated as: AVA= CM A x DVI/SVI. Mean pressure gradient and cardiac outputwere measured during catheterisation and the aortic valve areawas calculated by the Gorlin formula. Comparison between theaortic valve area determined by Doppler technique and catheterisationyielded a close correlation (r = 0.92, P<0.001), and therewas no significant difference between the two measurements.Good correlations of the instantaneous pressure gradient andthe stroke volume were also obtained between the two techniques(r = 0.91 and r = 0.90, respectively, P<0.001). These resultsdemonstrate that our Doppler echocardiographic method providesa promising approach to the noninvasive quantification of theaortic valve area in aortic stenosis     

经导管主动脉瓣置入术的初步经验

目的 评估经导管主动脉瓣置入术( TAVI)的安全性及有效性,并对初步的操作经验做一总结.方法 2010年10月至2011年5月,使用18 F Corevalve瓣膜系统对3例外科手术高危的重度钙化性主动脉瓣狭窄患者实施TAVI.分析3例患者的手术效果及并发症,总结相关的手术经验.结果 3例患者均完成手术,顺利出院.手术时间(109.0±22.6)min,X线曝光时间(24.0±9.5)min.术后患者的主动脉跨瓣压差从(84±15)mm Hg(1 mm Hg =0.133 kPa)降至(6±3)mm Hg,并有轻微至轻度瓣周漏.病例1围手术期未发生并发症;病例2术后出现一过性完全性左束支传导阻滞;病例3出现三度房室传导阻滞(置入永久心脏起搏器)、心包填塞(经心包穿刺引流等保守治疗后好转)及急性肾功能损害.结论 初步经验显示,使用18 F Corevalve瓣膜系统对高危的严重钙化性主动脉瓣狭窄患者行TAVI安全有效,但有一定的手术并发症.严格筛选患者、熟练掌握手术的技巧及相关注意事项可减少并发症的发生.