Key result
Absent RV contractile reserve predicts ~32% lower 5-year event-free survival after early mitral valve surgery.
Why the study?
The prognostic value of right ventricular contractile reserve during exercise echocardiography in patients with severe primary mitral regurgitation undergoing early surgery was unclear.
Does the lack of right ventricular contractile reserve during exercise echocardiography predict postoperative MACEs in asymptomatic patients with severe primary mitral regurgitation undergoing early surgery?
Cohort (n=142)
Does the lack of right ventricular contractile reserve during exercise echocardiography predict postoperative MACEs in asymptomatic patients with severe primary mitral regurgitation undergoing early surgery?
Hazard Ratio: 0.91 (95% CI 0.86–0.96)
Absolute Event Rate: 43.9% vs 75.8%
Lack of exercise-induced right ventricular contractile reserve (ex-TAPSE <26 mm) is a strong predictor of postoperative MACE in asymptomatic patients with severe primary mitral regurgitation undergoing early surgery.
May identify higher-risk patients after early mitral valve surgery in asymptomatic severe primary MR; leaves open whether exercise RV reserve should guide timing.
OBJECTIVE: To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery. METHODS: Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value. RESULTS: After median follow-up of 30 months (IQR 16-60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7). CONCLUSION: Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.
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Vitel et al. (2017) conducted a cohort in Primary mitral regurgitation (n=142). Lack of exercise-induced right ventricular contractile reserve vs. Presence of exercise-induced right ventricular contractile reserve was evaluated on Postoperative major adverse cardiovascular events (atrial fibrillation, stroke, cardiac-related hospitalisation or death) (HR 0.91, 95% CI 0.86-0.96). Lack of exercise-induced right ventricular contractile reserve predicted lower 5-year event-free survival after early mitral valve surgery compared to patients with reserve (43.9% vs 75.8%).
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