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CLINICAL RESEARCH: VALVULAR HEART DISEASE

Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation

Cardiology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Manuscript received February 25, 2009; revised manuscript received May 6, 2009, accepted June 1, 2009.

^_* Reprint requests and correspondence: Dr. Mariano Falconi, Cardiology Division, Hospital Italiano de Buenos Aires, Gascon 450, Ciudad Autonoma de Buenos Aires, Buenos Aires 1181, Argentina (Email: mariano.falconi{at}hospitalitaliano.org.ar).

Objectives: The purpose of the study was to determine the independent and additive prognostic value of brain natriuretic peptide (BNP) in patients with severe asymptomatic mitral regurgitation and normal left ventricular function.

Background: Early surgery could be advisable in selected patients with chronic severe mitral regurgitation, but there are no criteria to identify candidates who could benefit from this strategy. Assessment of BNP has not been studied in asymptomatic patients with severe mitral regurgitation; hence, its prognostic value remains unclear.

Methods: We prospectively evaluated 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%. The first 167 consecutive patients served as the derivation cohort, and the following 102 patients served as a validation cohort. The combined end point was the occurrence of either symptoms of congestive heart failure, left ventricular dysfunction, or death at follow-up.

Results: The end point was reached in 35 (21%) patients of the derivation set and in 21 (20.6%) patients of the validation cohort. The receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/ml of BNP that was able to discriminate patients at higher risk in both cohorts (76% vs. 5.4% and 66% vs. 4.0%, respectively). In both sets, BNP was the strongest independent predictor by multivariate analysis.

Conclusions: Among patients with severe asymptomatic organic mitral regurgitation, BNP 105 pg/ml discriminates a subgroup of patients at higher risk. Because of its incremental prognostic value, BNP assessment should be considered in clinical routine workup for risk stratification.

Key Words: mitral regurgitation • natriuretic peptide • prognosis

Abbreviations and Acronyms   AV = atrial volume   BNP = brain natriuretic peptide   BSA = body surface area   CHF = congestive heart failure   CI = confidence interval   EROA = effective regurgitant orifice area   HR = hazard ratio   LVDSD = left ventricular dysfunction, symptoms of congestive heart failure, or death   NFL = new flail leaflet   NYHA = New York Heart Association   OR = odds ratio   ROC = receiver-operating characteristic

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