A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation
Key result
Higher secondary mitral regurgitation EROA is linked to ~42% higher 5-year mortality per SD.
- HR 1.42
- 95% CI 1.25 to 1.63
- P<0.001
- n=423
Why the study?
Diverging guideline definitions for quantitative assessment of severe secondary mitral regurgitation reflect a lacking link to mortality and cause ongoing debate.
Does a combined quantitative assessment of EROA, RegVol, and RegFrac improve mortality risk prediction in heart failure patients with secondary mitral regurgitation compared to established guidelines?
Study Design
Type
Cohort (n=423)
Structured PICO
Does a combined quantitative assessment of EROA, RegVol, and RegFrac improve mortality risk prediction in heart failure patients with secondary mitral regurgitation compared to established guidelines?
P
Population
423 heart failure patients receiving guideline-directed medical therapy evaluated for secondary mitral regurgitation severity and followed for 5 years.
E
Exposure
Quantitative assessment of secondary mitral regurgitation (sMR) using combined risk thresholds for effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac)
C
Comparator
Currently established guideline grading algorithms
O
Outcome
5-year mortalityhard clinical
Main Result
Hazard Ratio: 1.42 (95% CI 1.25–1.63)
p-value: p=<0.001
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We were able to show that a cut-off of 45 ml is sufficient. This will revolutionise the current treatment guidelines throughout the world – particularly in the spirit of precision medicine.”
“This will allow us to make a much better assessment of who needs the treatment and at what point.”
“Currently, surgery is only performed in the USA at 60 ml but at 30 ml in Europe.”
Implication
A unifying risk stratification concept combining EROA, RegVol, and RegFrac provides significantly better 5-year mortality discrimination in heart failure patients with secondary mitral regurgitation compared with currently established guideline algorithms.
Abstract
BACKGROUND Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate. OBJECTIVES The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy. METHODS This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac). RESULTS Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms. CONCLUSIONS Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading.
Discussion
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Cite This Study
Bartko et al. (2019) conducted a cohort in Heart failure with secondary mitral regurgitation (n=423). Secondary mitral regurgitation severity (1-SD increase in EROA) was evaluated on 5-year mortality (HR 1.42, 95% CI 1.25 to 1.63, p=<0.001). A 1-SD increase in secondary mitral regurgitation effective regurgitant orifice area was associated with higher 5-year mortality in heart failure patients (HR 1.42; 95% CI 1.25-1.63; P<0.001).