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      B-Type Natriuretic Peptide in Isolated Severe Tricuspid Regurgitation: Determinants and Impact on Outcome

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          Abstract

          Background

          The plasma B-type natriuretic peptide (BNP) level is a useful prognostic marker in heart failure and valvular heart disease. In patients with isolated severe tricuspid regurgitation (TR), little is known about the determinants of plasma BNP levels and the correlation with future outcome. The purpose of this study was to identify the determinants of plasma BNP levels in patients with isolated severe TR and the value of the BNP level in predicting postoperative outcomes after corrective surgery.

          Methods

          We prospectively enrolled 39 patients with isolated, severe TR undergoing corrective surgery. A plasma BNP assay and cardiac magnetic resonance (CMR) imaging were performed before surgery. The combined end-point was the occurrence of cardiac death or readmission due to heart failure.

          Results

          Linear regression analysis showed that the left ventricular ejection fraction and right ventricular end systolic volume were the most important determinants of the BNP levels ( p = 0.002, R 2 = 0.315). Based on the receiver operating characteristics (ROC) curve, we were able to derive an optimal cutoff value (200 pg/mL) to predict postoperative cardiac death with a sensitivity of 80% and a specificity of 85%. The one-year survival rate was 96% in patients with a BNP < 200 pg/mL and 53% in patients with a BNP ≥ 200 pg/dL ( p = 0.001).

          Conclusion

          An elevation in the BNP level is determined by the functional status of the right and left ventricles in patients with isolated, severe TR. An elevated BNP predicts adverse events after corrective surgery. Therefore, the BNP level should be included in the clinical evaluation and risk stratification of patients with isolated TR.

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          Brain natriuretic peptide as a novel cardiac hormone in humans. Evidence for an exquisite dual natriuretic peptide system, atrial natriuretic peptide and brain natriuretic peptide.

          H Yasue, M Mukoyama, K Obata … (1991)
          Using a specific radioimmunoassay for human brain natriuretic peptide (hBNP) with a monoclonal antibody, we have investigated its synthesis, secretion, and clearance in comparison with those of atrial natriuretic peptide (ANP) in normal subjects and patients with congestive heart failure (CHF). Mean BNP-like immunoreactivity (-LI) levels in normal atrium and ventricle were 250 and 18 pmol/g, respectively. The plasma BNP-LI level in normal subjects was 0.90 +/- 0.07 fmol/ml, which was 16% of the ANP-LI level. In contrast, the plasma BNP-LI level markedly increased in patients with CHF in proportion to its severity, and surpassed the ANP-LI level in severe cases. There was a significant step-up of the plasma BNP-LI level in the coronary sinus (CS) compared with that in the aortic root (Ao) and the difference between these BNP-LI levels, delta(CS-Ao)BNP, also increased with the severity of CHF. In addition, the step-up of the BNP-LI level in the anterior interventricular vein [delta(AIV-Ao)BNP] was comparable to delta(CS-Ao)BNP, indicating that BNP is secreted mainly from the ventricle. Predominant BNP synthesis in the ventricle was also confirmed by Northern blot analysis. Catheterization and pharmacokinetic studies revealed that hBNP is cleared from the circulation more slowly than alpha-hANP; this was in part attributed to lower (about 7%) binding affinity of hBNP to clearance receptors than that of alpha-hANP. A predominant molecular form of BNP-LI in the heart and plasma was a 3-kD form corresponding to hBNP. These results indicate that BNP is a novel cardiac hormone secreted predominantly from the ventricle, and that the synthesis, secretion and clearance of BNP differ from those of ANP, suggesting discrete physiological and pathophysiological roles of BNP in a dual natriuretic peptide system.
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            Determinants of surgical outcome in patients with isolated tricuspid regurgitation.

            In-Su Park, Hyuk Ahn, Doh Kwan Kim … (2009)
            We sought to identify preoperative predictors of clinical outcomes after surgery in patients with severe tricuspid regurgitation. We prospectively enrolled 61 consecutive patients (54 women, aged 57+/-9 years) with isolated severe tricuspid regurgitation undergoing corrective surgery. Twenty-one patients (34%) were in New York Heart Association functional class II, 35 (57%) in class III, and 5 (9%) in class IV. Fifty-seven patients (93%) had previous history of left-sided valve surgery. Preoperative echocardiography revealed pulmonary artery systolic pressure of 41.5+/-8.7 mm Hg, right ventricular (RV) end-diastolic area of 35.1+/-9.0 cm(2), and RV fractional area change of 41.3+/-8.4%. The median follow-up duration after surgery was 32 months (range, 12 to 70). Six of the 61 patients died before discharge; thus, operative mortality was 10%. Three of the 55 patients who survived surgery died during follow-up, and 6 patients required readmission because of cardiovascular problems. Thus, 46 patients (75%) remained event free at the end of follow-up. In the 54 patients who underwent 6-month clinical and echocardiographic follow-up, RV end-diastolic area decreased by 29%, with a corresponding 26% reduction in RV fractional area change. Thirty-three patients (61%) showed improved functional capacity after surgery. On multivariable Cox regression analysis, preoperative hemoglobin level (P 11.3 g/dL predicted event-free survival with a sensitivity of 73% and a specificity of 83%. Timely correction of severe tricuspid regurgitation carries an acceptable risk and improves functional capacity. Surgery should be considered before the development of advanced RV systolic dysfunction and before the development of anemia.
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              Determinants of the severity of functional tricuspid regurgitation.

              Ho Kim, Hyuk Ahn, Doh Kwan Kim … (2006)
              We performed a prospective study of patients with chronic right ventricular (RV) dilation to determine the factors associated with the degree of functional tricuspid regurgitation (FTR). We prospectively enrolled 64 patients with chronic RV dilation and measured right atrial (RA) area, RV area and its fractional area change (RVFAC), tricuspid annular diameter and contraction, tricuspid valve (TV) tethering area, and systolic pulmonary artery pressure. We also measured the RV eccentricity index and the RV sphericity index for simple presentation of RV geometry. Regurgitant orifice area of FTR was obtained for the quantification of FTR. End-systolic RV eccentricity index (r=0.73), end-diastolic RV eccentricity index (r=0.56), RA area (r=0.49), TV tethering area (r=0.37), age (r=0.31), end-systolic (r=0.42) and end-diastolic (r=0.30) tricuspid annular diameters, and left ventricular ejection fraction (r=-0.37) were significantly related to the regurgitant orifice area of FTR in univariate analysis. However, RV area, RVFAC, and systolic pulmonary artery pressure were not. In multivariate analysis, the end-systolic RV eccentricity index (p 2.0, 69% and 73% with an end-systolic tethering area>1.0 cm2, and 64% and 59% for an end-systolic tricuspid annulus diameter>3.9 cm, respectively. FTR severity was found to show the best correlation with the end-systolic RV eccentricity index. In conclusion, these findings underscore the importance of eccentric RV dilation for determining FTR severity and should lead to the development of more rational surgical approaches to FTR beyond TV annuloplasty.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Cardiovasc Ultrasound
                Journal ID (publisher-id): JCU
                Title: Journal of Cardiovascular Ultrasound
                Publisher: Korean Society of Echocardiography
                ISSN (Print): 1975-4612
                ISSN (Electronic): 2005-9655
                Publication date (Print): December 2010
                Publication date (Electronic): 31 December 2010
                Volume: 18
                Issue: 4
                Pages: 139-145
                Affiliations
                [1 ]Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea.
                [2 ]Cardiovascular Center, Seoul National University Boramae Hospital, Seoul, Korea.
                [3 ]Cardiovascular Center, Seoul National University Hospital, Seoul, Korea.
                [4 ]Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
                [5 ]Department of Thoracic Surgery, Seoul National University College of Medicine, Seoul, Korea.
                Author notes
                Address for Correspondence: Joo-Hee Zo, Department of Internal Medicine, Seoul National University Boramae Hospital, 41 Boramae-gil, Dongjak-gu, Seoul 156-707, Korea. Tel: +82-2-870-2214, Fax: +82-2-870-3866, jooheezo@ 123456brm.co.kr
                Article
                DOI: 10.4250/jcu.2010.18.4.139
                PMC ID: 3021892
                PubMed ID: 21253363
                SO-VID: fa09974b-1ed1-4028-b02a-6120f4af840b
                Copyright © Copyright © 2010 Korean Society of Echocardiography
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 09 November 2010
                Date revision received : 25 November 2010
                Date accepted : 25 November 2010
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: tricuspid regurgitation,b-type natriuretic peptide,cardiac magnetic resonance,surgery
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: tricuspid regurgitation, b-type natriuretic peptide, cardiac magnetic resonance, surgery

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