Overweight status increased MR improvement likelihood by 70%, reduced LVEF by 50%, and aortic stenosis by 58%, while left atrial enlargement decreased it by 42%.
Overweight status, reduced LVEF, and aortic stenosis are independent predictors of spontaneous improvement in mitral regurgitation severity, suggesting a period of observation and medical optimization may be warranted before invasive interventions in these patients.
Abstract Background Patients with significant mitral regurgitation (MR) are often considered appropriate candidates for invasive procedures. However, with advancements in pharmacotherapy for patients with heart failure, it is not uncommon to see improvement in the severity of MR. Purpose This study aims to identify clinical and echocardiographic predictors of non-interventional improvement in MR. Methods This study is based on 261,478 transthoracic echocardiograms (TTE) from 124,093 unique patients within the SHEBAHEART database, a big data registry from a single tertiary center. The inclusion criteria for this analysis required patients to have undergone more than one echocardiographic assessment between 2007 and 2024, with at least moderate MR present in their initial baseline echocardiogram. The primary endpoint was defined as an improvement in MR severity, which was categorized as either a decrease of ≥2 severity grades ("criterion 1") in follow-up TTE, or a ≥1 grade decrease in two consecutive follow-up studies ("criterion 2"). Univariate and multivariate binary logistic regression models were employed to identify predictors of MR improvement. Landmark survival analysis was performed with follow-up period starting at the last echocardiography evaluation. Results The final study cohort comprised 2,541 patients, with a median age of 74 years (IQR, 63-82), of whom 1,181 (47%) were women. MR severity was moderate, moderate to severe and severe in 1,496 (59%), 535 (21%), and 509 (20%) respectively. The average number of echocardiography evaluations per patient was 3 (IQR, 2-4), with a median of 4 months (IQR 0.5-15) between the first baseline study and the first follow up study. Overall, 1,068 (42%) patients demonstrated improvement in MR severity, with 788 (74%) improving according to criterion 1 and 280 (26%) improving according to criterion 2, over a median follow-up duration of 1.3 years (IQR, 0.2-3.9) until the last echocardiographic assessment. Multivariable binary logistic regression analysis revealed that overweight status, reduced left ventricular ejection fraction (LVEF), and aortic stenosis (AS) were all independently associated with a significant 70%, 50%, and 58% increase in the likelihood of MR improvement over time, respectively (95% CI: 1.29-2.2, 1.1-2.0, 1.05-2.37 respectively; p .001 for overweight status, and p .05 for LVEF and AS). Conversely, left atrial enlargement was associated with a significant 42% decreased likelihood of MR improvement over time (95% CI: 0.35-0.97; p .05). A landmark survival analysis demonstrated similar survival rates among patients who did or did not improve their MR degree. Conclusion Although MR is typically managed invasively, this study identifies patients in whom the severity of MR tends to improve over time, highlighting the importance of exercising caution before proceeding with invasive interventions in such cases.Central illustration
Elimeleh et al. (2025) studied this question. Overweight status increased MR improvement likelihood by 70%, reduced LVEF by 50%, and aortic stenosis by 58%, while left atrial enlargement decreased it by 42%.