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Functional Mitral Regurgitation Outcome and Grading in HFrEF
Quick Takes
- Among patients with HFrEF and functional mitral regurgitation (FMR), the amount of FMR (assessed by effective regurgitant orifice area [EROA]) is skewed toward low values.
- Excess mortality for FMR was observed at an EROA threshold of ~0.10 cm2.
- The authors propose a quantitative grading scheme for FMR by EROA that is more granular than AHA/ACC or ESC criteria.
Study Questions:
Among patients with heart failure with reduced ejection fraction (HFrEF), is there excess mortality associated with the presence and severity of functional mitral regurgitation (FMR)?
Methods:
At a single large referral center, patients with HFrEF (EF <50%) Stage B-C who were diagnosed between 2003 and 2011 and had routine FMR quantitation on echocardiography (FMR cohort, n = 6,381) were analyzed for excess mortality within the cohort, in comparison to the general population, and in comparison to a simultaneous cohort of patients with degenerative mitral regurgitation (DMR; n = 2,416).
Results:
Of 6,381 patients in the FMR cohort (aged 70 ± 11 years, EF 36 ± 10%), 3,823 patients (60%) had no FMR and 2,558 patients (40%) had some amount of quantified FMR (effective regurgitant orifice area [EROA] ≥0.01 cm2). The distribution of EROA for the whole FMR cohort was skewed towards low values (EROA ≥0.40 cm2 in only 8% vs. 38% for the DMR cohort, p < 0.0001). One-year mortality was 15.6%, increasing from 13.3% without FMR to 28.5% with EROA ≥0.30 cm2 (adjusted odds ratio, 1.57; 95% confidence interval [CI], 1.19-2.97; p = 0.001). During a follow-up interval of 4.1 years (1.1-7.1 years), 3,538 patients in the FMR cohort died. Excess mortality in the FMR cohort was observed at an EROA threshold of approximately 0.10 cm2 (vs. a threshold EROA of ~0.20 cm2 in the DMR cohort), with 0.10 cm2 EROA increments independently associated with incrementally increased mortality (adjusted hazard ratio, 1.11; 95% CI, 1.08-1.15; p < 0.0001). EROA was the strongest FMR marker associated with survival. Compared to American Heart Association/American College of Cardiology (AHA/ACC) (EROA <0.20 cm2, 0.2-0.39 cm2, ≥0.40 cm2) and European Society of Cardiology (ESC) grading criteria of FMR (<0.20 cm2, ≥0.20 cm2), an expanded FMR grading scale (0.01-0.09 cm2, 0.10-0.19 cm2, 0.20-0.29 cm2, ≥0.30 cm2) added incremental prognostic power.
Conclusions:
Among patients with HFrEF, FMR was skewed towards small EROA values; excess mortality increased exponentially above an EROA threshold of approximately 0.10 cm2, with a steeper slope than among patients with DMR. The authors found that an expanded EROA-based stratification scheme better correlated with survival than did AHA/ACC or ESC FMR grading criteria, concluding that this should allow guideline harmonization.
Perspective:
The presence of FMR has long been associated with worse outcomes among patients with HFrEF, and the disparate findings of MITRA-FR and COAPT trials piqued interest in whether, in whom, and how intervention for FMR should be pursued. This difficult to decipher manuscript presents a lot of data that are not necessarily well organized or well explained, but appears to support the observation that even a small amount of FMR (EROA > ~0.10 cm2) is associated with higher mortality among patients with HFrEF. Although it shows a correlation between more granular quantitation of FMR and mortality, the study does not address whether intervention affects outcome at any level.
Clinical Topics: Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Valvular Heart Disease, Acute Heart Failure, Echocardiography/Ultrasound, Mitral Regurgitation
Keywords: Diagnostic Imaging, Echocardiography, Geriatrics, Heart Failure, Heart Valve Diseases, Mitral Valve Insufficiency, Outcome Assessment, Health Care, Stroke Volume, Ventricular Dysfunction, Left
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