Predictors of Long-Term Outcomes in Patients With Significant Myxomatous Mitral Regurgitation Undergoing Exercise Echocardiography

Naji, Peyman; Griffin, Brian P.; Asfahan, Fadi; Barr, Tyler; Rodriguez, L. Leonardo; Grimm, Richard A.; Agarwal, Shikhar; Stewart, William J.; Mihaljević, Tomislav; Gillinov, A. Marc; Desai, Milind Y.

doi:10.1161/circulationaha.113.005287

Cited by 59 publications

(38 citation statements)

References 47 publications

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“…5 However, many patients are unaware of the onset of symptoms because of their gradual onset and their unwitting ability to subtly reduce exercise to prevent symptoms from occurring. 8 Furthermore, LV dysfunction is difficult to assess in severe MR, and LV contractility may already be irreversibly impaired, even though left ventricular ejection fraction (LVEF) remains in the usual normal range. Previous reports have shown that outcome after MV surgery is impaired once preoperative LVEF is <60%, and, thus, an LVEF <60% is considered abnormal and a potential indication for surgery in severe MR. 3 Additionally, impaired LVEF postoperatively (<50%) has been shown to predict poorer long-term survival.…”

mentioning

confidence: 99%

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

Alashi

Mentias

Patel

et al. 2016

Circ: Cardiovascular Imaging

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I n the developed world, myxomatous degeneration of the mitral valve (MV) is the most common cause of mitral regurgitation (MR).1,2 Surgical correction remains the cornerstone of management in severe primary MR because medical management alone does not improve the hemodynamic consequences of the regurgitant valve and its impact on outcome. 3,4 According to the most recent guidelines, indications for surgical intervention in patients with severe primary MR are development of symptoms, asymptomatic left ventricular (LV) systolic dysfunction, new-onset AF, or pulmonary arterial hypertension.5 However, appropriate timing of surgical intervention in asymptomatic severe primary MR is often challenging. Advances in MV repair have led to excellent long-term results with low morbidity and mortality at experienced centers 6,7 such that the threshold to recommend surgical intervention at these centers has been lowered by the guidelines when Background-In asymptomatic patients with ≥3+ mitral regurgitation and preserved left ventricular (LV) ejection fraction who underwent mitral valve surgery, we sought to discover whether baseline LV global longitudinal strain (LV-GLS) and brain natriuretic peptide provided incremental prognostic utility. Methods and Results-Four hundred and forty-eight asymptomatic patients (61±12 years and 69% men) with ≥3+ primary mitral regurgitation and preserved left ventricular ejection fraction, who underwent mitral valve surgery (92% repair) at our center between 2005 and 2008, were studied. Baseline clinical and echocardiographic data (including LV-GLS using Velocity Vector Imaging, Siemens, PA) were recorded. The Society of Thoracic Surgeons score was calculated. The primary outcome was death. Mean Society of Thoracic Surgeons score, left ventricular ejection fraction, mitral effective regurgitant orifice, indexed LV end-diastolic volume, and right ventricular systolic pressure were 4±1%, 62±3%, 0.55±0.2 cm 2 , 58±13 cc/m 2 , and 37±15 mm Hg, respectively. Forty-five percent of patients had flail. Median log-transformed BNP and LV-GLS were 4.04 (absolute brain natriuretic peptide: 60 pg/dL) and −20.7%. At 7.7±2 years, death occurred in 41 patients (9%; 0% at 30 days). On Cox analysis, a higher Society of Thoracic Surgeons score (hazard ratio 1.55), higher baseline right ventricular systolic pressure (hazard ratio 1.11), more abnormal LV-GLS (hazard ratio 1.17), and higher median log-transformed BNP (hazard ratio 2.26) were associated with worse longer-term survival (all P<0.01). Addition of LV-GLS and median log-transformed BNP to a clinical model (Society of Thoracic Surgeons score and baseline right ventricular systolic pressure) provided incremental prognostic utility (χ 2 for longer-term mortality increased from 31-47 to 61; P<0.001). Conclusions-In asymptomatic patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction who underwent mitral valve surgery, brain natriuretic peptide and LV-GLS provided synergistic risk stratification, independent o...

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confidence: 99%

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

Alashi

Mentias

Patel

et al. 2016

Circ: Cardiovascular Imaging

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“…The right contractile property is important because right ventricular remodeling may play an important role in clinical outcome of patients undergoing mitral valve surgery [17,18].…”

Section: Discussionmentioning

confidence: 99%

Contractile Properties of the Right Atrial Myofilaments in Patients with Myxomatous Mitral Valve Degeneration

Sikand¹,

Bening²,

Conzelmann³

et al. 2015

Thorac cardiovasc Surg

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Background: Myxomatous degeneration of the mitral valve is a common pathological finding in mitral valve surgery and the most common reason for severe mitral valve regurgitation. Considering the importance of right ventricular remodeling and global function after mitral valve surgery we tried to elucidate a possible association of myxomatous mitral valve and impairment of right atrial and ventricular function, which might have an impact on global ventricular performance after mitral valve surgery. Methods: Right atrial tissue was harvested from 47 patients undergoing mitral valve surgery. We took the trabeculae from the right auricle, which was resected at the right auricle for implementation of extracorporal circulation. The tissue was skinned and prepared in a 24 h-lasting procedure to create small fibers for hinging them in the "muscle machine", an experimental set-up, created for pCa-force measurements. Results: Patients without myxomatous mitral valve developed significantly more force (4.0 mN ± 0.8 mN) at the highest step of calcium concentration compared to 2.7 mN ± 0.4 mN in group of patients with myxomatous valve degeneration (p 0.03). Calcium sensitivity in the myxomatous valve group was at pCa 6.0 and in the non-myxomatous group at pCa 5. Furthermore we observed a significant difference in ejection fraction (EF) among the groups: 49% in the non-myxomatous group versus 57% in the myxomatous group (p 0.03). In the non-myxomatous group 5 patients had diastolic dysfunction grade I-II (22,7%), in group I 10 patients (40%). This was also significant (p 0.04). Conclusions: Patients with myxomatous mitral valve degeneration seem to have reduced force capacities. Calcium sensitivity is higher compared to the non-myxomatous group, which might be a compensatory mechanism to cover the physiological demand. Furthermore we suggest a higher incidence of diastolic dysfunction in patients with myxomatous mitral valve degeneration, which might have an impact on ventricular remodeling after mitral valve surgery.

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“…62 Alashi et al examined 448 asymptomatic patients with severe primary mitral regurgitation and preserved ejection fraction and demonstrated that abnormal longitudinal strain and higher BNP levels are associated with higher long-term mortality and the combination of two appeared to be a synergistic outcome predictor. 63 The importance of exercise capacity in predicting outcomes in patients with severe primary regurgitation was studied by Naji et al 64,65 In 576 patients with primary mitral regurgitation who underwent exercise echocardiography prior to mitral valve surgery, lower achieved METs were associated with worse long-term outcomes. The authors concluded that achieving >100% of age and gender-predicted METs can safely delay mitral valve surgery for at least one year, without an effect on outcomes.…”

Section: Natural History Progression and Predictors Of Outcomes In Mmentioning

confidence: 99%

Primary mitral valve regurgitation: Update and review

Apostolidou

Maslow

Poppas

2017

gcsp

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Mitral regurgitation is the second most common valvular disorder requiring surgical intervention worldwide. This review summarizes the current understanding of primary, degenerative mitral regurgitation with respect to etiology, comprehensive assessment, natural history and management. The new concept of staging of the valvular disorders, newer predictors of adverse and controversy of ‘‘watchful waiting’’ versus ‘‘early surgical intervention’’ for severe, asymptomatic, primary mitral regurgitation are addressed.

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Predictors of Long-Term Outcomes in Patients With Significant Myxomatous Mitral Regurgitation Undergoing Exercise Echocardiography

Cited by 59 publications

References 47 publications

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery

Contractile Properties of the Right Atrial Myofilaments in Patients with Myxomatous Mitral Valve Degeneration

Primary mitral valve regurgitation: Update and review

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