Extramitral Valvular Cardiac Involvement in Patients With Significant Secondary Mitral Regurgitation

Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR. Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR. Guideline-directed medical therapy for heart failure (including cardiac resynchronization therapy CRT) has been demonstrated to reverse left ventricular (LV) remodeling and reduce secondary mitral regurgitation (SMR) in selected patients.1Nasser R Van Assche L Vorlat A Vermeulen T Van Craenenbroeck E Conraads V Van der Meiren V Shivalkar B Van Herck P Claeys MJ. Evolution of functional mitral regurgitation and prognosis in medically managed heart failure patients with reduced ejection fraction.JACC Heart Fail. 2017; 5: 652-659Crossref PubMed Scopus (72) Google Scholar,2St John Sutton MG Plappert T Abraham WT Smith AL DeLurgio DB Leon AR Loh E Kocovic DZ Fisher WG Ellestad M Messenger J Kruger K Hilpisch KE Hill MR Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study Group. 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Impact of recurrent mitral regurgitation after mitral valve repair for functional mitral regurgitation: long-term analysis of competing outcomes.Eur Heart J. 2019; 40: 2206-2214Crossref PubMed Scopus (42) Google Scholar More recently, transcatheter mitral valve repair with MitraClip (Abbott, Abbott Park, Illinois) was demonstrated to improve the prognosis of selected patients with heart failure and SMR with symptoms refractory to medical therapy.7Stone GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google Scholar The echocardiographic criteria that indicate the need for mitral valve intervention comprise measures of SMR severity, LV ejection fraction (LVEF), and LV volumes.7Stone GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google Scholar, 8Baumgartner H Falk V Bax JJ De Bonis M Hamm C Holm PJ Iung B Lancellotti P Lansac E Rodriguez Muñoz D Rosenhek R Sjögren J Tornos Mas P Vahanian A Walther T Wendler O Windecker S Zamorano JL ESC Scientific Document Group2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar, 9Nishimura RA Otto CM Bonow RO Carabello BA 3rd Erwin JP Fleisher LA Jneid H Mack MJ McLeod CJ O'Gara PT Rigolin VH Sundt 3rd, TM Thompson A 2017 aha/acc focused update of the 2014 aha/acc guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol. 2017; 70: 252-289Crossref PubMed Scopus (1781) Google Scholar However, the spectrum of cardiac abnormalities that accompany SMR and that influence patient outcomes is broader. Cardiac classification algorithms have been applied to severe aortic stenosis and have shown that extra-aortic valve, cardiac involvement provides incremental prognostic value over measures of aortic stenosis severity.10Généreux P Pibarot P Redfors B Mack MJ Makkar RR Jaber WA Svensson LG Kapadia S Tuzcu EM Thourani VH Babaliaros V Herrmann HC Szeto WY Cohen DJ Lindman BR McAndrew T Alu MC Douglas PS Hahn RT Kodali SK Smith CR Miller DC Webb JG Leon MB. Staging classification of aortic stenosis based on the extent of cardiac damage.Eur Heart J. 2017; 38: 3351-3358Crossref PubMed Scopus (217) Google Scholar Accordingly, the present study proposes an algorithm to divide patients with SMR into groups based on their extramitral valve, cardiac involvement and evaluated its prognostic implications. Patients with moderate and severe SMR (significant SMR) and reduced LVEF 34 ml/m2 and/or history of atrial fibrillation); group 3: tricuspid valve or pulmonary artery vasculature involvement (systolic pulmonary artery pressure SPAP ≥40 mm Hg and/or significant tricuspid regurgitation TR); group 4: right ventricular (RV) involvement (tricuspid annular plane systolic excursion TAPSE ≤17 mm). Importantly, patients were classified according to the highest cardiac involvement group; thus, for example, if patients had LVEF <50% and TAPSE ≤17 mm, they were included in group 4. Patients with previous mitral valve intervention (surgical mitral valve repair, mitral valve replacement, or transcatheter edge-to-edge mitral valve repair) or incomplete echocardiographic data to determine the extramitral valvular cardiac involvement were excluded. Clinical and demographic data were collected using the departmental patient information system. For retrospective analysis of clinically acquired data which were anonymously handled, the institutional review board waived the need for patient was performed with the patients at in the left using with or and data were acquired from and LV end-diastolic diameter was on the LP V J A L E T Lancellotti P D L for cardiac in an update from the American of and the Association of Heart J Cardiovasc PubMed Scopus Google Scholar The and were to the LV end-diastolic and and LVEF was according to LP V J A L E T Lancellotti P D L for cardiac in an update from the American of and the Association of Heart J Cardiovasc PubMed Scopus Google Scholar LA were at the end of ventricular on the and using the of and for (LA volume LP V J A L E T Lancellotti P D L for cardiac in an update from the American of and the Association of Heart J Cardiovasc PubMed Scopus Google Scholar volume was with the volume = LV of the LV WA D Bonow RO M E Grayburn PA Hahn RT Hung J DJ S P Weissman for of valvular regurgitation: a report from the American of in with the for Am 2017; Full Text Full Text PDF PubMed Scopus Google Scholar The of mitral regurgitation was according to using and were according to the for which the was and volume was the mitral valve WA D Bonow RO M E Grayburn PA Hahn RT Hung J DJ S P Weissman for of valvular regurgitation: a report from the American of in with the for Am 2017; Full Text Full Text PDF PubMed Scopus Google P C A BA T LA L Zamorano JL Scientific Document of the Association of for the echocardiographic of valvular regurgitation: an from the Association of Heart J Cardiovasc 2013; PubMed Scopus Google Scholar The of was using moderate to and severe WA D Bonow RO M E Grayburn PA Hahn RT Hung J DJ S P Weissman for of valvular regurgitation: a report from the American of in with the for Am 2017; Full Text Full Text PDF PubMed Scopus Google P C A BA T LA L Zamorano JL Scientific Document of the Association of for the echocardiographic of valvular regurgitation: an from the Association of Heart J Cardiovasc 2013; PubMed Scopus Google Scholar was defined moderate or severe systolic function was using the TAPSE on the focused and LP V J A L E T Lancellotti P D L for cardiac in an update from the American of and the Association of Heart J Cardiovasc PubMed Scopus Google LG J L K for the echocardiographic of the right heart in a report from the American of the Association of a of the of and the of Am Full Text Full Text PDF PubMed Scopus Google Scholar the the pressure was from the of the according to the to which the right atrial pressure was identified the and diameter of the were LP V J A L E T Lancellotti P D L for cardiac in an update from the American of and the Association of Heart J Cardiovasc PubMed Scopus Google LG J L K for the echocardiographic of the right heart in a report from the American of the Association of a of the of and the of Am Full Text Full Text PDF PubMed Scopus Google Scholar Patients were for the of mitral valve intervention surgical mitral valve repair, mitral valve replacement, and edge-to-edge mitral valve repair) and all-cause mortality. 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PubMed Scopus Google Scholar left of LV and mitral regurgitation can volume and pressure which can to LV and LA LA can pulmonary that can in with and H M Tuzcu EM B Kapadia in mitral Am Heart PubMed Scopus Google J D E and of the right Am Coll Cardiol. 2019; PubMed Scopus Google Scholar The prevalence of extramitral valvular cardiac involvement in patients with SMR has been GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google U P D S L De ventricular is a of in patients with moderate to severe mitral regurgitation and left ventricular Heart J. PubMed Scopus Google Scholar, S K K T H M T cardiac after mitral for severe functional mitral Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar, J Pibarot P PP E Rosenhek R Lancellotti P in valvular disease: a review on to therapy from the Cardiovasc PubMed Scopus Google Scholar, A of tricuspid regurgitation after functional ischemic mitral Google Scholar, D G Iung B G T C F D M P F C E L M E B F D C G P Vahanian A repair or medical treatment for secondary mitral regurgitation.N Engl J Med. 2018; 379: PubMed Scopus Google Scholar, S H J M R D S S H Impact of functional mitral regurgitation on right ventricular function and in patients with right ventricular J Cardiol. Full Text Full Text PDF PubMed Scopus Google Scholar has been in of patients with severe D G Iung B G T C F D M P F C E L M E B F D C G P Vahanian A repair or medical treatment for secondary mitral regurgitation.N Engl J Med. 2018; 379: PubMed Scopus Google Scholar and in moderate-to-severe and severe GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google Scholar has been in of the patients who mitral valve A of tricuspid regurgitation after functional ischemic mitral Google Scholar The prevalence of pulmonary in patients with SMR and LV systolic is J Pibarot P PP E Rosenhek R Lancellotti P in valvular disease: a review on to therapy from the Cardiovasc PubMed Scopus Google Scholar study an of ≥40 mm Hg in of the patients with severe S K K T H M T cardiac after mitral for severe functional mitral Thorac Cardiovasc Surg. Full Text Full Text PDF PubMed Scopus Google Scholar is present in to of patients with at moderate U P D S L De ventricular is a of in patients with moderate to severe mitral regurgitation and left ventricular Heart J. PubMed Scopus Google S H J M R D S S H Impact of functional mitral regurgitation on right ventricular function and in patients with right ventricular J Cardiol. Full Text Full Text PDF PubMed Scopus Google Scholar study provides the prevalence of of cardiac involvement and classified Group involvement, was the that patient is of a with heart have shown an between the groups of cardiac involvement and outcomes in patients with SMR. LV F A F L V C C G A implications of functional mitral regurgitation according to the of the chronic heart a long-term J Heart Fail. PubMed Scopus Google A Faggiano P E M S A M S M prognostic value of functional mitral regurgitation in patients with heart A analysis of patients with and PubMed Scopus Google Scholar and LA G E A G C R V S L functional mitral regurgitation left atrial function in heart failure and prognostic Heart J Cardiovasc 2019; PubMed Scopus Google A M S AL DL CM Heart of left atrial size and mortality in patients with heart an patient of data heart J Heart Fail. 2009; 11: PubMed Scopus Google Scholar have been independently associated with an risk for mortality. 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