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Primary Mitral Regurgitation Extra-Valvular Cardiac Involvement
Quick Takes
- This study describes a system for the assessment of extra-cardiac involvement of primary MR, progressing from LV involvement (LV enlargement or systolic dysfunction) to LA involvement (LA enlargement or atrial fibrillation) to pulmonary involvement (pulmonary hypertension or TR) to RV involvement (systolic dysfunction assessed by TAPSE).
- All-cause mortality was significantly worse in association with the higher extra-cardiac involvement group. On multivariable analysis, age, male sex, chronic obstructive pulmonary disease, kidney function, and group of cardiac involvement were independently associated with all-cause mortality.
Study Questions:
What is the prognostic impact of extra–mitral valve cardiac involvement among patients with primary mitral regurgitation (MR)?
Methods:
Patients with moderate-to-severe or severe primary MR undergoing surgery at one of two European tertiary referral centers between 2000–2017 and who had available preoperative echocardiography were included in the analysis; patients with infective endocarditis, rheumatic heart disease, or prior valve intervention were excluded. Clinical data were extracted from medical records. Preoperative echocardiograms were analyzed for what was defined as extra–cardiac involvement: group 0, no cardiac involvement; group 1, left ventricular (LV) involvement (LV end-systolic diameter ≥40 mm, LV end-systolic volume index ≥30 mL/m2, or LV ejection fraction ≤60%); group 2, left atrial (LA) involvement (LA maximum diameter ≥55 mm or history of atrial fibrillation); group 3, pulmonary artery vasculature or tricuspid valve involvement (systolic pulmonary artery pressure >50 mm Hg or tricuspid regurgitation [TR] grade >2); or group 4, right ventricular (RV) involvement (tricuspid annular plane systolic excursion [TAPSE] ≤17 mm). Patients were assigned to the highest group with associated findings. The primary outcome measure was all-cause mortality.
Results:
A total of 1,106 patients were included (mean age 63 ± 12 years, 68% male). Of these, 377 patients (34%) were classified in group 0, 239 (22%) in group 1, 213 (19%) in group 2, 180 (16%) in group 3, and 97 (9%) in group 4. Kaplan-Meier curve analysis revealed significantly worse survival (log-rank chi-square = 43.4; p < 0.001) with higher group. Mortality was higher among patients with LA dilation compared to those with LV dilation, and RV involvement was associated with the highest rate of mortality. On multivariable analysis, age, male sex, chronic obstructive pulmonary disease, kidney function, and group of cardiac involvement were independently associated with all-cause mortality. For each increase in group, a 17% higher risk for all-cause mortality was observed (95% confidence interval, 1.051-1.313; p = 0.005) during a median follow-up of 88 months.
Conclusions:
Among patients with moderate-to-severe or severe primary MR who underwent surgery, a novel classification system based on extra–mitral valve cardiac involvement was associated with all-cause mortality; the authors concluded that the classification system might help refine risk stratification and the timing of surgery.
Perspective:
This study found that echocardiography/Doppler evidence of extra-cardiac disease (progressively from LV involvement [LV enlargement or systolic dysfunction] to LA involvement [LA enlargement or atrial fibrillation] to pulmonary involvement [pulmonary hypertension or TR] to RV involvement [systolic dysfunction assessed by TAPSE]) was associated with progressively higher all-cause mortality among patients with primary MR who underwent surgical intervention. Although the anticipated compensatory response to chronic severe primary MR would suggest that LA and LV changes occur before pulmonary vascular disease and eventual RV systolic dysfunction, this pattern was not necessarily evident in this study cohort; suggesting either that the pathophysiology of chronic MR is different in various patients, or that extra-cardiac findings did not necessarily occur entirely in response to MR. Improvements in the assessment of the risks associated with chronic severe MR and the timing of surgical intervention are of interest; this study leaves open questions of causation, and does not test whether altered timing of surgical intervention would affect mortality outcomes.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Pulmonary Hypertension, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Mitral Regurgitation
Keywords: Atrial Fibrillation, Cardiac Surgical Procedures, Diagnostic Imaging, Dilatation, Echocardiography, Heart Valve Diseases, Hypertension, Pulmonary, Kidney Diseases, Mitral Valve Insufficiency, Outcome Assessment, Health Care, Pulmonary Disease, Chronic Obstructive, Risk Assessment, Stroke Volume, Tricuspid Valve Insufficiency, Ventricular Dysfunction
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