Speckle–tracking–based Staging of Extra–valvular Cardiac Damage in Degenerative Mitral Regurgitation: Prognostic Implications

Aims In asymptomatic patients with severe primary mitral regurgitation (MR), surgical referral is based on two–dimensional echocardiographic indices that often identify advanced myocardial injury. Speckle–tracking echocardiography (STE) may detect earlier, reversible dysfunction. This study evaluated whether a novel multi–chamber STE–based staging system of extra–valvular cardiac damage improves risk stratification in patients with severe degenerative MR undergoing surgery. Methods Retrospective multicenter cohort study of patients with degenerative MR undergoing surgery: derivation cohort (n = 208; mean age 64 ± 13 years; 59.7% men) and validation cohort (n = 92; mean age 63 ± 12 years; 53.3% men). Receiver operating characteristic curve analysis identified optimal strain cut–offs associated with adverse outcomes: left ventricular global longitudinal strain (LVGLS) ‹ 20%, peak atrial longitudinal strain (PALS) ‹ 25%, and right ventricular free–wall longitudinal strain (RVFWLS) ‹ 17%. Patients were classified into four stages: Stage 0, no damage; Stage 1, left atrial damage (PALS ‹ 25%); Stage 2, left ventricular damage (LVGLS ‹ 20%); Stage 3, right ventricular damage (RVFWLS ‹ 17%) (Figure 1). Results The STE–based staging system was independently associated with the composite of periprocedural adverse events (mortality, stroke, myocardial infarction, acute kidney injury, life–threatening bleeding or sepsis/wound infection requiring reintervention, complete atrioventricular block requiring pacemaker implantation): odds ratio 1.68 per stage increase (CI 1.24–2.32; p = 0.001) (Figure 2, 3). Predictive accuracy was higher compared with clinical and echocardiographic data, with consistent results in the validation cohort. Conclusions The multi–chamber STE staging system provides incremental prognostic information beyond conventional parameters, improving perioperative risk stratification.