Key result
Post-surgery RV FAC is the only RV parameter linked to long-term mortality in PMR patients.
Why the study?
TAPSE is considered unreliable after cardiac surgery, and little is known about postoperative changes in other RV functional parameters or in RA size and function following PMR surgery.
Which immediate post-operative right ventricular functional parameters are associated with all-cause mortality in patients undergoing surgery for primary mitral regurgitation?
Cohort (n=702)
Which immediate post-operative right ventricular functional parameters are associated with all-cause mortality in patients undergoing surgery for primary mitral regurgitation?
Following surgery for primary mitral regurgitation, right ventricular fractional area change (FAC) is the only immediate post-operative RV parameter independently associated with long-term all-cause mortality, making it a valuable tool for risk stratification.
Positions FAC as a potentially superior prognostic marker over TAPSE post-surgery; leaves.
Background Tricuspid annular plane systolic excursion (TAPSE) is a widely used parameter to assess right ventricular (RV) function in patients with primary mitral regurgitation (PMR), but is considered unreliable after cardiac surgery. However, little is known about the post-operative changes in other RV functional parameters, or in right atrial (RA) size and function. Purpose To assess the changes in RV and RA after PMR surgery, and to evaluate their association with outcome. Methods Patients who underwent surgery for PMR and had echocardiograms available before surgery and immediately post-operative (pre-discharge) were included. TAPSE, fractional area change (FAC), RV longitudinal (RVLS) and free-wall (RVFWLS) strains, RA volume index (RAVI) and RA reservoir strain (RASr) were measured. A subgroup analysis was performed in patients with a longer-term follow-up echocardiography available. Study endpoint was all cause mortality. Results A total of 702 patients were included, of which 351 (50%) received concomitant tricuspid valve repair (TVP). Compared to baseline, TAPSE (23.2 vs 10.7 mm), RVLS (-19.9 vs -15.4%) and RVFWLS (-23.9 vs -16.8%) significantly decreased immediately postoperative (p<0.001), while FAC did not show significant change (40.6 vs 41.1%, p=0.138, Fig 1-a). Similarly, RAVI (26.8 vs 22.9 mL/m2, p<0.001) became significantly smaller, while RASr (32.7 vs 9.7%, p<0.001) showed a marked impairment. Of interest, there was no significant effect of TVP on the changes in RV parameters (Fig 1-b), but patients who received TVP experienced significantly less drop in RASr (interaction p<0.001), while RAVI was smaller only in patients who received TVP (interaction p<0.001). A follow-up echocardiography after a median of 12 (8-17) months was available in 358 (51%) patients. TAPSE, RVLS, RVFWLS and RASr all improved compared to immediate post-operative echocardiography (p<0.001), albeit not to baseline values (Fig 2-a). In turn, FAC further improved compared to baseline and the immediate post-operative values (41.3 to 43.7%, p<0.001). At a median follow-up of 8.6 years, 85 (12%) patients died. Multivariable Cox regression analysis (including clinical and echocardiographic variables) showed that, among the immediate post-operative RV parameters, FAC was the only measurement independently associated with all-cause mortality (Fig 2-b). Conclusion This is the first study to systematically report on changes in right heart measures following surgery for PMR, and particularly including RA assessment. After surgery, RAVI became significantly smaller but RASr showed a striking reduction. Similarly, all RV functional parameters showed a significant reduction postoperative, except for FAC, which significantly improved at 1-year follow-up and was independently associated with all-cause mortality. This index might therefore be used to identify patients with true RV impairment in the post-operative setting and improve risk stratification.Immediate postoperative changes Long term follow-up
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Elmasry et al. (2026) conducted a cohort in Primary mitral regurgitation (n=702). Surgery for primary mitral regurgitation vs. Baseline (pre-operative) was evaluated on All cause mortality. Surgery for primary mitral regurgitation was followed by a 12% all-cause mortality rate at 8.6 years, with post-operative fractional area change being the only independent predictor of mortality.
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