Key result
Concomitant functional mitral regurgitation ≥2+ with additional risk factors increased the risk of heart failure outcomes after aortic valve replacement in patients with aortic stenosis (HR 2.7; P=0.004).
Why the study?
Does concomitant functional mitral regurgitation and specific clinical/echocardiographic risk factors predict adverse outcomes in patients undergoing aortic valve replacement?
Cohort (n=848)
Does concomitant functional mitral regurgitation and specific clinical/echocardiographic risk factors predict adverse outcomes in patients undergoing aortic valve replacement?
While FMR >= 2+ alone does not independently reduce survival after AVR, specific high-risk echocardiographic and clinical features identify patients at significantly increased risk for heart failure and persistent mitral regurgitation.
May inform post-AVR surveillance in high-risk aortic stenosis; leaves open whether mitral intervention improves outcomes.
BACKGROUND: Concomitant functional mitral regurgitation (FMR) in patients undergoing aortic valve replacement (AVR) is frequently not corrected because it may improve after AVR; however, data supporting this assumption are sparse. We ascertained the impact of clinical and echocardiographic parameters on the outcome of patients with or without concomitant FMR at the time of AVR. METHODS AND RESULTS: Clinical and echocardiographic follow-up was performed on 848 patients who underwent AVR after 1990. Risk factors for mortality and a composite outcome of heart failure (CHF) symptoms, CHF death, or subsequent mitral repair or replacement, were examined with bootstrapped Cox proportional hazard models. Follow-up was 4591 patient-years (mean 5.4+/-3.4 years; maximum 14.2 years). FMR > or = 2+ had no independent adverse effect on survival in patients with aortic stenosis (AS) or insufficiency (AI). However, AS patients with FMR > or = 2+ and 1 additional risk factor (left atrial diameter >5 cm, preoperative peak aortic valve gradient <60 mm Hg, or atrial fibrillation) were at increased risk for the composite outcome (hazard ratio [HR]: 2.7; P=0.004). AI patients with FMR > or = 2+ and a left ventricular end-systolic diameter <45 mm were also at risk (HR: 4.0; P=0.02). Clinical risk factors in the AS and AI subgroups were associated with an increased likelihood of mitral regurgitation > or = 2+ at 18 months postoperatively. CONCLUSIONS: AS patients with FMR > or = 2+ and a left atrial diameter >5 cm, preoperative peak aortic valve gradient <60 mm Hg, or atrial fibrillation have a significantly higher risk of CHF and persistent mitral regurgitation after AVR than other AS patients. AI patients with FMR > or = 2+ and a left ventricular end-systolic diameter <45 mm preoperatively are also at increased risk. Others fare well after AVR.
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Ruel et al. (2006) conducted a cohort in Concomitant functional mitral regurgitation in patients undergoing aortic valve replacement (n=848). Functional mitral regurgitation ≥ 2+ with additional risk factors vs. Patients without functional mitral regurgitation ≥ 2+ or without additional risk factors was evaluated on Composite outcome of heart failure (CHF) symptoms, CHF death, or subsequent mitral repair or replacement (HR 2.7, p=0.004). Concomitant functional mitral regurgitation ≥2+ with additional risk factors increased the risk of heart failure outcomes after aortic valve replacement in patients with aortic stenosis (HR 2.7; P=0.004).
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