Clinical and Prognostic Impact of a New Left Ventricular Ejection Index in Primary Mitral Regurgitation Because of Mitral Valve Prolapse

Abstract

Background— To prevent left ventricular dysfunction (LVD), surgery is recommended in patients with severe primary mitral regurgitation as soon as ejection fraction (EF) ≤60% or LV end-systolic diameter ≥40 mm. However, LVD may be concealed behind preoperative normal LVEF and LV end-systolic diameter. We sought to identify whether a new composite echocardiographic Doppler marker of the LV ejection according to the LV dilatation may predict postoperative LVD and outcome after mitral valve repair in patients with primary mitral regurgitation. Methods and Results— Between 1991 and 2010, patients who underwent mitral valve repair for primary mitral regurgitation were studied. From preoperative echocardiography, we calculated LV ejection index (LVEI) using following formula: LVEI=indexed LV end-systolic diameter/LV outflow tract time–velocity integral. In the 278 patients included, the best correlation with postoperative LVEF was found with LVEI ( r =−0.40; P <0.0001), even in patients with preoperative LVEF≥60% ( r =−0.46; P <0.0001). In multivariable analysis, LCEI>1.13 was an independent predictor of postoperative LVD ( P <0.0001). During a mean follow-up of 10±4.6 years, 67 (29%) deaths occurred. When compared with patients with preserved LVEI, those with LVEI>1.13 had significantly lower both survival and cardiac death–free survival ( P =0.017 and P =0.008, respectively). Similar results were found in patients with preoperative LVEF≥60% ( P =0.049 and P =0.016, respectively). In Cox proportional hazard model, after meticulous adjustment for cofactors, LVEI>1.13 remains independently associated with death (hazard ratio, 1.64; P =0.039) and cardiac-related death (hazard ratio, 3.27; P =0.026). Conclusions— After mitral valve repair for primary mitral regurgitation, the preoperative LVEI is a new and simple composite parameter of both LV dilatation and LV forward flow able to accurately predict postoperative LVD and outcome.

Forward Left Ventricular Ejection Fraction: A Simple Risk Marker in Patients With Primary Mitral Regurgitation

“…Hence, these findings suggest that, although it does not reflect the true LVEF, the forward LVEF is more sensitive than the total LVEF to detect subclinical LV dysfunction and predict risk of adverse events in primary MR. Consistent with our results, Magne et al recently reported that the “LV ejection index,” calculated by dividing the indexed LV end‐systolic diameter by LV outflow tract time‐velocity integral, was a better predictor of mortality and LV dysfunction after surgery than total LVEF . Our results, however, suggest that forward LVEF may be superior to the LV ejection index to predict outcomes in primary MR, especially the need of MV surgery.…”

“…Consistent with our results, Magne et al recently reported that the "LV ejection index," calculated by dividing the indexed LV end-systolic diameter by LV outflow tract timevelocity integral, was a better predictor of mortality and LV dysfunction after surgery than total LVEF. 21 Our results, however, suggest that forward LVEF may be superior to the LV ejection index to predict outcomes in primary MR, especially the need of MV surgery. Several studies 15,29,35 reported that a substantial proportion of patients may have a significant deterioration of total LVEF immediately after MV surgery.…”

Determinants of prolonged hospitalization in patients who underwent trans-femoral transcatheter aortic valve implantation

“…We should discuss why moderate or severe MR was significantly associated with prolonged hospitalization. Because patients in the present study were very elderly (83.7 ±5.1 years old), the etiology of MR would be secondary such as volume over caused by heart failure rather than primary such as mitral valve prolapse [23,24]. As peri-operative ADHF was the second most common reason for prolonged hospitalization, moderate or severe MR might reflect the severity of ADHF before trans-femoral TAVI.…”

Management of Asymptomatic Severe Degenerative Mitral Regurgitation

“…A LV ejection index >1.13 is associated with post-operative LV dysfunction and mortality, even in patients with a pre-operative LVEF >60%. 14 Although not included in the guidelines as part of the surgical criteria, it is nevertheless a handy parameter that takes into account both the size and function of the LV.…”