Natural history of the asymptomatic/minimally symptomatic patient with severe mitral regurgitation secondary to mitral valve prolapse and normal right and left ventricular performance

Rosen, Stacey E.; Borer, Jeffrey S.; Hochreiter, Clare; Supino, Phyllis G.; Roman, Mary J.; Devereux, Richard B.; Kligfield, Paul; Bucek, John

doi:10.1016/0002-9149(94)90406-5

Cited by 151 publications

(82 citation statements)

References 27 publications

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“…The population included patients enrolled in our ongoing prospective study of the natural histories of regurgitant valvular diseases and their predictors (protocol previously described [1,7,9]). Briefly, at study entry, among other tests, patients undergo echocardiography at rest, radionuclide cineangiography at rest and exercise, and ETT with ECG.…”

Section: Study Populationmentioning

confidence: 99%

“…During follow-up, 25/38 patients (68%) in the cohort reached a primary endpoint event (first event: sudden death=1, heart failure=2, atrial fibrillation=4, LV ejection fraction<60%=2, LVIDs≥45mm=12; 4 patients had multiple endpoints simultaneously (LV ejection fraction<60% + LVIDs≥45mm [3], heart failure + LV ejection fraction<60% + LVIDs≥45mm [1]). Among the 24 patients whose LVIDs did not exceed 40mm at baseline, 11 developed LVIDs>40mm, 10 without reaching another endpoint and 1 in association with another endpoint: average annual risk (using LVIDs≥45mm) among the entire population was 14.2% (15.5% using LVIDs≥40mm); 5-year cardiac event-free survival rate was 40.0% (35.5% using LVIDs≥40mm).…”

Section: Events During Follow-upmentioning

confidence: 99%

“…exercise treadmill testing; exercise capacity; mitral regurgitation; prognostication Among asymptomatic patients with chronic, isolated, severe mitral regurgitation (MR) with normal left (LV) and right ventricular (RV) chamber performance, progression to heart failure occurs at a rate of 10%/year (1). When symptoms have developed, natural history is suboptimal even if ventricular performance is well preserved and valve surgery is performed (2).…”

Section: Introductionmentioning

confidence: 99%

“…When symptoms have developed, natural history is suboptimal even if ventricular performance is well preserved and valve surgery is performed (2). Therefore, regardless of etiology, asymptomatic patients with severe MR are closely followed to detect symptoms and/or objective ventricular dysfunction (1,3). Symptom perception varies with activity and can be difficult to elicit.…”

Section: Introductionmentioning

confidence: 99%

“…ECG response to exercise was "positive" only when ≥0.1 mV (1 mm) additional horizontal or downsloping ST segment depression occurred during exercise compared with rest at 60 to 80 msec after the J point; upsloping ST segment depression and/or subthreshold ST depression were "negative." Echocardiography at rest and radionuclide cineangiography at rest and during symptom limited exercise were performed by standard methods as previously described (1,(12)(13)(14). Follow-up clinical status was evaluated by a combination of personal or telephone interview and review of medical and vital records.…”

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confidence: 99%

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Prognostic Value of Exercise Tolerance Testing in Asymptomatic Chronic Nonischemic Mitral Regurgitation

Supino

Borer

Schuleri

et al. 2007

The American Journal of Cardiology

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In many heart diseases, exercise treadmill testing(ETT) has useful functional correlates and/or prognostic value. However, its predictive value in mitral regurgitation(MR) is undefined. To determine whether ETT descriptors predict death or indications for mitral valve surgery among patients with MR, we prospectively followed, for 7±3 endpoint-free years, a cohort of 38 patients with chronic severe nonischemic MR who underwent modified Bruce ETT; all lacked surgical indications at study entry. Their baseline exercise descriptors also were compared with those from 46 patients with severe MR who, at entry, already had reached surgical indications. Endpoints during follow-up among the cohort included sudden death(n=1), heart failure symptoms(n=2), atrial fibrillation(n=4), LVEF<60%(n=2), LV systolic dimensions(IDs)≥45 mm(n=12) and LVIDs>40mm(n=11), LVEF<60%+LVIDs 45 mm(n=3), and heart failure+LVIDs 45mm +LVEF<60%(n=1). In univariate analysis, exercise duration(p=.004), chronotropic response(p=. 007), percent predicted peak heart rate(p=.01) and heart rate recovery(p<.02) predicted events; in multivariate analysis, only exercise duration was predictive(p<.02). Average annual event risk was 5-fold lower(4.62%) with exercise duration≥15 minutes vs. <15 minutes(average annual risk=23.48%, p=.004). Relative risks among patients with and without exercise-inducible ST segment depression were comparable(≤1.3 [NS]) whether defined at entry and/or during follow-up. Exercise duration, but not prevalence of exercise-inducible ST segment depression, was lower(p<. 001) among patients with surgical indications at entry vs. initially endpoint-free patients. In conclusion, among asymptomatic patients with chronic severe nonischemic MR and no objective criteria for operation, progression to surgical indications generally is rapid. However, those with excellent exercise tolerance have a relatively benign course. Exercise-inducible ST segment depression has no prognostic value in this population.We followed, for 7±3 endpoint-free years, 38 patients with chronic severe nonischemic mitral regurgitation (MR) who underwent modified Bruce exercise treadmill testing (ETT) to determine whether ETT descriptors predict death or indications for mitral valve surgery. At study entry, all lacked surgical indications. Exercise duration independently predicted subsequent events; event risks among patients with and without exercise-inducible ST segment depression were comparable. We conclude that among asymptomatic patients with chronic severe nonischemic MR Address for Correspondence: Jeffrey S. Borer, M.D., New York-Presbyterian Hospital New York Weill Cornell Center, 525 East 68 th Street, New York, N.Y. 10021, 212-746-4646=phone, 212-746-8448=fax, canadaD45@aol.com=email Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulti...

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Section: Study Populationmentioning

confidence: 99%

Section: Events During Follow-upmentioning

confidence: 99%