Key result
Elevated baseline RVSP independently predicts higher long-term mortality in primary MR with preserved LVEF.
Why the study?
Primary mitral regurgitation is a growing health problem due to the aging population, prompting this study to assess the impact of baseline pulmonary hypertension on long-term outcomes in patients with significant primary MR and preserved LVEF.
Does baseline pulmonary hypertension (right ventricular systolic pressure) impact long-term mortality in patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction?
Cohort (n=1,318)
No
Does baseline pulmonary hypertension (right ventricular systolic pressure) impact long-term mortality in patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction?
In patients with significant primary mitral regurgitation and preserved LVEF, baseline right ventricular systolic pressure is progressively and independently associated with long-term mortality and improves risk reclassification when added to the STS score.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“The current study supported that surgery should not be delayed in the presence of significant PH in patients with primary MR. Nevertheless, waiting for SPAP to progress to ≥50 mm Hg to treat MR is likely to expose patients to a markedly compromised prognosis and persistent post-operative PH.”
“In a recent study by our group, we showed that the impact of RVSP in this population is progressive and not necessary limited to those with the highest baseline values (9). In our study cohort, every 10 mmHg increase in baseline RVSP above normal cutoff of 30 mmHg was associated with 23% increase in risk of long-term mortality in follow up (9).”
“The present study by Mentias et al. again showed the prognostic impact of SPAP was progressive from 35 mmHg (7). In the severity spectrum of primary MR, PH can be considered as a general haemodynamic phenomenon rather than a specific complication. The probable threshold indicating permanent pulmonary vascular remodelling appears to be around an SPAP of 35 mmHg.”
May inform risk stratification in primary MR; leaves open whether pressures should modify intervention thresholds.
BACKGROUND: Primary mitral regurgitation (MR) is a growing health problem due to the aging population. OBJECTIVES: The purpose of this study was to assess the impact of baseline pulmonary hypertension on long-term outcomes in patients with significant primary MR and preserved left ventricular ejection fraction (LVEF). METHODS: We studied 1,318 patients with ≥3+ primary MR and LVEF ≥60% using echocardiography at rest; they were evaluated at our center from 2005 to 2008. Baseline clinical and echocardiography data were recorded, and the Society of Thoracic Surgeons (STS) score was calculated. The primary outcome was death. RESULTS: Mean STS score was 3.98 ± 1%; 54% of patients were in New York Heart Association (NYHA) functional class I and 31% were in NYHA functional class II; and 18% had atrial fibrillation (AF). Mean LVEF, mitral effective regurgitant orifice, indexed LV end-systolic diameter (LVESD), and right ventricular systolic pressure (RVSP) were 62 ± 2%, 0.56 ± 0.30 cm(2), 1.6 ± 0.3 cm/m(2), and 37 ± 14 mm Hg, respectively. At 7.1 ± 2.0 years, 86% had mitral valve (MV) surgery. Death occurred in 130 (10%) patients. On Cox multivariable analysis, baseline RVSP, together with age, baseline NYHA functional class, pre-operative AF, coronary artery disease, and indexed LVESD were associated with a higher rate of longer term mortality (all p < 0.01), whereas MV surgery (as a time-dependent covariate) was associated with improved survival (p < 0.001). Addition of RVSP to the STS score significantly reclassified the risk for longer term mortality (integrated discrimination index: 0.07; p < 0.001); 77% patients who died had RVSP ≥35 mm Hg. CONCLUSIONS: In patients with significant primary MR and preserved LVEF, baseline RVSP is independently associated with long-term survival. Impact of RVSP is progressive and not confined to those with the highest baseline values.
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Mentias et al. (2016) conducted a cohort in Primary mitral regurgitation (n=1,318). Baseline right ventricular systolic pressure (RVSP) / pulmonary hypertension was evaluated on Death (long-term mortality) (p=<0.01). Baseline RVSP independently predicted long-term mortality (p<0.01) and improved risk reclassification over the STS score (IDI 0.07; p<0.001) in primary MR with LVEF ≥60%.
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