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August 14, 2026Journal of Cardiovascular Development and DiseaseOpen Access

Cardiopulmonary Exercise Testing and Exercise Stress Echocardiography in Degenerative Mitral Regurgitation: An Exploratory Analysis of Functional and Left Ventricular Outcomes After Surgery

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Key result

Preoperative CPET and ESE fail to predict early functional improvement or LVEF changes after surgery.

  • P>0.15
  • n=60

Why the study?

Conventional clinical and resting echocardiographic parameters may underestimate myocardial impairment in severe degenerative mitral regurgitation, whereas CPET and ESE may offer a more complete assessment.

Do preoperative cardiopulmonary exercise testing and exercise stress echocardiography parameters predict early functional and left ventricular outcomes after surgery in patients with severe degenerative mitral regurgitation?

Population

60 patients with severe DMR who underwent CPET and ESE before surgery

Comparison

Patients who functionally improved vs those who did not after surgery

Design

Exploratory observational study

Authors

LBLaura BesolaUniversity of PisaGBGiulia BacciUniversity of PisaCPCinzia Anna Maria PapappiccoUniversity of Padua

Discussion

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Implication

Preoperative CPET and ESE parameters should not yet guide decisions in severe degenerative mitral regurgitation; leaves open their prognostic value in larger prospective studies.

Key Points

  • To characterize preoperative CPET and ESE findings in severe degenerative mitral regurgitation and evaluate their association with early postoperative functional and left ventricular outcomes.
  • Included N=60 patients with severe degenerative mitral regurgitation and preserved left ventricular function undergoing CPET and ESE before surgical correction.
  • Evaluated functional improvement (≥1 NYHA class gain at early follow-up) and change in left ventricular ejection fraction (Delta LVEF from discharge to follow-up), incorporating exploratory random forest modeling.
  • CPET showed abnormal exercise capacity (peak oxygen uptake 17.2 ± 5 mL/kg/min; VE/VCO2 slope 33 ± 8.9; oxygen uptake efficiency slope 1.6), while ESE demonstrated stroke volume increase from 51.0 mL to 72.5 ± 21.6 mL and cardiac output increase from 3.8 L/min to 9.0 ± 3.2 L/min.
  • No baseline clinical, CPET, or ESE parameters significantly distinguished patients with functional improvement from those without, early Delta LVEF was negligible, and random forest models did not discriminate above chance.

Study Design

Type

Observational (n=60)

Multicenter

No

Structured PICO

Do preoperative cardiopulmonary exercise testing and exercise stress echocardiography parameters predict early functional and left ventricular outcomes after surgery in patients with severe degenerative mitral regurgitation?

P
Population
60 patients with severe degenerative mitral regurgitation and preserved left ventricular ejection fraction who underwent surgical correction and preoperative CPET and ESE, followed for a median of 6.4 months.
E
Exposure
Preoperative cardiopulmonary exercise testing (CPET) and exercise stress echocardiography (ESE)
O
Outcome
Improvement of functional status (improvement of at least one NYHA class from preoperative baseline to early follow-up) and change in LV function (continuous change in LVEF between discharge and early follow-up at median 6.4 months)surrogate

Main Result

p-value: p=>0.15

Patients with severe degenerative mitral regurgitation and preserved LVEF exhibit objectively abnormal exercise responses on CPET and ESE despite mild symptoms, supporting the use of these modalities for functional characterization.

Limitations

  • Retrospective, single-center analysis with a small sample size (60 patients), leading to a high risk of overfitting and lack of statistical power for multivariable modeling.
  • Postoperative functional evaluation relied only on NYHA class grading, which might be imprecise.
  • Short follow-up period (6 months) to evaluate the effects of surgery.
  • Use of LVEF changes to assess modifications in postoperative myocardial function can be misleading due to the regurgitant fraction.
  • Small sample size (60 operated patients, with only 39 and 32 evaluable for NYHA and LVEF outcomes)
  • Retrospective observational design
  • Single-center study
  • Unstable variable-importance rankings in random forest analysis due to small sample size

Cite This Study

Besola et al. (2026) conducted an observational in Severe degenerative Mitral Regurgitation (DMR) (n=60). Preoperative cardiopulmonary exercise testing (CPET) and exercise stress echocardiography (ESE) parameters vs. Patients without functional improvement was evaluated on Improvement of at least one NYHA class from preoperative baseline to early follow-up (p=>0.15). Preoperative cardiopulmonary exercise testing and exercise stress echocardiography parameters did not significantly predict early functional improvement or changes in left ventricular ejection fraction after surgery in patients with severe degenerative mitral regurgitation.

synapsesocial.com/papers/6a7ec735b70b84ec8b9135bchttps://doi.org/10.3390/jcdd13080383
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