Chest
Volume 128, Issue 4, October 2005, Pages 2563-2570
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Clinical Investigations
Plasma N-Terminal Pro-Brain Natriuretic Peptide as a Marker of Right Ventricular Dysfunction in Patients With Tetralogy of Fallot After Surgical Repair

https://doi.org/10.1378/chest.128.4.2563Get rights and content

Objective

Chronic heart failure is associated with neurohormonal activation that is not only related to outcome but is also a therapeutic target. We have attempted to demonstrate whether a similar pattern of neurohormonal activation exists in adult congenital heart disease (ACHD) and, if so, whether it relates to disease severity determined by cardiopulmonary exercise testing.

Methods and results

Concentrations of N-terminal pro-atrial natriuretic peptide, N-terminal pro-brain natriuretic peptide (NT-proBNP), endothelin (ET)-1, renin, aldosterone, adrenalin, and noradrenalin were determined in 50 adults (mean age, 27.8 ± 1.7 years [± SEM]; 26 women) with tetralogy of Fallot (TOF) after surgical repair (New York Heart Association functional class 1.1 ± 0.1). One hundred age- and sex-matched healthy blood donors served as a control group for NT-proBNP determination. Dimensions of ventricles, left ventricular pump function, and estimated right ventricular (RV) systolic pressure were determined by echocardiography. Maximum oxygen uptake ( V˙ o2 max) was measured in all patients using spiroergometry. TOF patients had elevated levels of NT-proBNP compared with healthy individuals: NT-proBNP (women: 180 pg/mL vs 43 pg/mL, and men: 147 pg/mL vs 32 pg/mL; p < 0.0001) and ET-1 (2.5 fmol/L vs 0.7 fmol/L). There was a significant correlation of NT-proBNP to dimension and estimated peak systolic pressure of the RV as well as impairment of V˙ o2 max.

Conclusions

RV dysfunction detected by echocardiography and plasma NT-proBNP determination in asymptomatic or minimally symptomatic TOF patients correlates well with their cardiopulmonary exercise capacity. Thus, these simple and noninvasive screening methods can be used additionally to stratify ACHD patients with impaired cardiac function before they become clinically symptomatic.

Section snippets

Study Population

We performed a prospectively designed detailed assessment of clinical and neurohormonal variables in 50 adult patients with TOF (26 women and 24 men) > 20 years after surgical repair. Patients were consecutively recruited from the specialized ACHD outpatient clinic of the Georg-August-University of Göttingen between January 2001 and September 2003. All the tests for each patient were carried out on the same day. One hundred age- and sex-matched healthy blood donors served as a control group for

Clinical Variables

The clinical and demographic characteristics of the 50 patients included in this study are given in Table 1. Age at operation, current age, and follow-up after operation in both groups (male and female) were similar. Ninety-six percent of male patients and 89% of female patients were classified as NYHA functional class I, and the rest were classified as NYHA functional class II. Sixty-eight percent of male and 57% of female patients underwent palliative procedures before surgical repair

Discussion

Most long-term follow-up studies in patients with TOF after cardiac surgery reveal good results of corrective repair.118192021 In Germany, the survival rate 20 years and 30 years after surgical repair is estimated to be 94% and 89%, respectively.2 However, the success of surgery depends also on the remaining morbidity of the surviving patients. Since the investigated patient group shows residual defects such as pulmonary stenosis, PR, and often tricuspid regurgitation, long-term RV pressure and

Conclusion

In 50 adults with TOF after corrective surgery, the cardiopulmonary capacity ( V˙ o2 max) and neurohormonal activities were determined, and hemodynamic status was evaluated by two-dimensional echocardiography. The patients showed reduced V˙ o2 max, elevated NT-proBNP, and increased RV size and systolic pressure. LV size and pump function were normal. Between V˙ o2 max and NT-proBNP, there was a significant inverse correlation. We found also a correlation between RV size,

ACKNOWLEDGMENT

We thank our study nurse Barbara Formanek, and Renate Lucyga, Ursula Baumgarten, and Sabine Laurenzano for technical assistance; and Talāt Mesud Yelbuz, MD, PhD, for critical reading of the manuscript and suggestions for improvement.

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