Impact of Duration of Mitral Regurgitation on Outcomes in Asymptomatic Patients with Myxomatous Mitral Valve Undergoing Exercise Stress Echocardiography

Overview

Journal J Am Heart Assoc

Specialty Cardiology & Vascular Diseases

Date 2015 Feb 13

PMID 25672368

Citations 3

Authors

Peyman Naji

Fadi Asfahan

Tyler Barr

L Leonardo Rodriguez

Richard A Grimm

Shikhar Agarwal

James D Thomas

A Marc Gillinov

Tomislav Mihaljevic

Brian P Griffin

Milind Y Desai

Affiliations

Soon will be listed here.

Abstract

Background: Significant mitral regurgitation (MR) typically occurs as holosystolic (HS) or mid-late systolic (MLS), with differences in volumetric impact on the left ventricle (LV). We sought to assess outcomes of degenerative MR patients undergoing exercise echocardiography, separated based on MR duration (MLS versus HS).

Methods And Results: We included 609 consecutive patients with ≥III+myxomatous MR undergoing exercise echocardiography: HS (n=487) and MLS (n=122). MLS MR was defined as delayed appearance of MR signal during mid-late systole on continuous-wave Doppler while HS MR occurred throughout systole. Composite events of death and congestive heart failure were recorded. Compared to MLS MR, HS MR patients were older (60±14 versus 53±14 years), more were males (72% versus 53%), and had greater prevalence of atrial fibrillation (16% versus 7%; all P<0.01). HS MR patients had higher right ventricular systolic pressure (RVSP) at rest (33±11 versus 27±9 mm Hg), more flail leaflets (36% versus 6%), and a lower number of metabolic equivalents (METs) achieved (9.5±3 versus 10.5±3), compared to the MLS MR group (all P<0.05). There were 54 events during 7.1±3 years of follow-up. On step-wise multivariable analysis, HS versus MLS MR (HR 4.99 [1.21 to 20.14]), higher LV ejection fraction (hazard ratio [HR], 0.94 [0.89 to 0.98]), atrial fibrillation (HR, 2.59 [1.33 to 5.11]), higher RVSP (HR, 1.05 [1.03 to 1.09]), and higher percentage of age- and gender-predicted METs (HR, 0.98 [0.97 to 0.99]) were independently associated with adverse outcomes (all P<0.05).

Conclusion: In patients with ≥III+myxomatous MR undergoing exercise echocardiography, holosystolic MR is associated with adverse outcomes, independent of other predictors.

Citing Articles

Impact of Chest Wall Conformation on the Outcome of Primary Mitral Regurgitation due to Mitral Valve Prolapse.

Sonaglioni A, Nicolosi G, Rigamonti E, Lombardo M J Cardiovasc Echogr. 2022; 32(1):29-37.

PMID: 35669134 PMC: 9164916. DOI: 10.4103/jcecho.jcecho_71_21.

Impact of Mitral Regurgitation Severity and Cause on Effort Tolerance-Integrated Stress Myocardial Perfusion Imaging and Echocardiographic Assessment of Patients With Known or Suspected Coronary Artery Disease Undergoing Exercise Treadmill Testing.

Kampaktsis P, Albert B, Kim J, Xie L, Brouwer L, Tehrani N J Am Heart Assoc. 2019; 8(5):e010974.

PMID: 30808228 PMC: 6474934. DOI: 10.1161/JAHA.118.010974.

Exercise capacity in asymptomatic patients with significant primary mitral regurgitation: independent effect of global longitudinal left ventricular strain.

Mentias A, Alashi A, Naji P, Gillinov A, Rodriguez L, Mihaljevic T Cardiovasc Diagn Ther. 2018; 8(4):460-468.

PMID: 30214861 PMC: 6129839. DOI: 10.21037/cdt.2018.05.03.

References

Tribouilloy C, Enriquez-Sarano M, Schaff H, Orszulak T, Bailey K, Tajik A . Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation. 1999; 99(3):400-5. DOI: 10.1161/01.cir.99.3.400. View

Leung D, Griffin B, Snader C, Luthern L, Thomas J, Marwick T . Determinants of functional capacity in chronic mitral regurgitation unassociated with coronary artery disease or left ventricular dysfunction. Am J Cardiol. 1997; 79(7):914-20. DOI: 10.1016/s0002-9149(97)00014-3. View

Enriquez-Sarano M, Avierinos J, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V . Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005; 352(9):875-83. DOI: 10.1056/NEJMoa041451. View

Gulati M, Black H, Shaw L, Arnsdorf M, Merz C, Lauer M . The prognostic value of a nomogram for exercise capacity in women. N Engl J Med. 2005; 353(5):468-75. DOI: 10.1056/NEJMoa044154. View

Eguchi K, Ohtaki E, Matsumura T, Tanaka K, Tohbaru T, Iguchi N . Pre-operative atrial fibrillation as the key determinant of outcome of mitral valve repair for degenerative mitral regurgitation. Eur Heart J. 2005; 26(18):1866-72. DOI: 10.1093/eurheartj/ehi272. View

Lang R, Bierig M, Devereux R, Flachskampf F, Foster E, Pellikka P . Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of.... J Am Soc Echocardiogr. 2005; 18(12):1440-63. DOI: 10.1016/j.echo.2005.10.005. View

Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D . Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006; 113(18):2238-44. DOI: 10.1161/CIRCULATIONAHA.105.599175. View

Messika-Zeitoun D, Johnson B, Nkomo V, Avierinos J, Allison T, Scott C . Cardiopulmonary exercise testing determination of functional capacity in mitral regurgitation: physiologic and outcome implications. J Am Coll Cardiol. 2006; 47(12):2521-7. DOI: 10.1016/j.jacc.2006.02.043. View

Vahanian A, Baumgartner H, Bax J, Butchart E, Dion R, Filippatos G . Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007; 28(2):230-68. DOI: 10.1093/eurheartj/ehl428. View

10.

Pellikka P, Nagueh S, Elhendy A, Kuehl C, Sawada S . American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr. 2007; 20(9):1021-41. DOI: 10.1016/j.echo.2007.07.003. View

11.

Kim E, Ishwaran H, Blackstone E, Lauer M . External prognostic validations and comparisons of age- and gender-adjusted exercise capacity predictions. J Am Coll Cardiol. 2007; 50(19):1867-75. DOI: 10.1016/j.jacc.2007.08.003. View

12.

Hunt S, Abraham W, Chin M, Feldman A, Francis G, Ganiats T . 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines:.... Circulation. 2009; 119(14):e391-479. DOI: 10.1161/CIRCULATIONAHA.109.192065. View

13.

Tribouilloy C, Grigioni F, Avierinos J, Barbieri A, Rusinaru D, Szymanski C . Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. J Am Coll Cardiol. 2009; 54(21):1961-8. DOI: 10.1016/j.jacc.2009.06.047. View

14.

Magne J, Lancellotti P, Pierard L . Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation. 2010; 122(1):33-41. DOI: 10.1161/CIRCULATIONAHA.110.938241. View

15.

Magne J, Lancellotti P, Pierard L . Exercise-induced changes in degenerative mitral regurgitation. J Am Coll Cardiol. 2010; 56(4):300-9. DOI: 10.1016/j.jacc.2009.12.073. View

16.

Topilsky Y, Suri R, Schaff H, Enriquez-Sarano M . When to intervene for asymptomatic mitral valve regurgitation. Semin Thorac Cardiovasc Surg. 2010; 22(3):216-24. DOI: 10.1053/j.semtcvs.2010.10.004. View

17.

Rosenhek R . Watchful waiting for severe mitral regurgitation. Semin Thorac Cardiovasc Surg. 2011; 23(3):203-8. DOI: 10.1053/j.semtcvs.2011.09.002. View

18.

Topilsky Y, Michelena H, Bichara V, Maalouf J, Mahoney D, Enriquez-Sarano M . Mitral valve prolapse with mid-late systolic mitral regurgitation: pitfalls of evaluation and clinical outcome compared with holosystolic regurgitation. Circulation. 2012; 125(13):1643-51. DOI: 10.1161/CIRCULATIONAHA.111.055111. View

19.

Shah A, Desai B, Samad Z, Jollis J, Glower D . Comparison of need for operative therapy in patients with mitral valve prolapse involving both leaflets versus posterior leaflet only. Am J Cardiol. 2012; 110(9):1350-3. DOI: 10.1016/j.amjcard.2012.06.044. View

20.

Grayburn P, Weissman N, Zamorano J . Quantitation of mitral regurgitation. Circulation. 2012; 126(16):2005-17. DOI: 10.1161/CIRCULATIONAHA.112.121590. View