Prognostic Implications of Mitral Regurgitation in Patients With Severe Aortic Regurgitation

Abstract

Background— Mitral regurgitation (MR) is common in those with severe aortic regurgitation (AR) and can predispose to atrial fibrillation, heart failure, and a need for mitral valve surgery during aortic valve replacement (AVR). However, little data exist as to its clinical and prognostic implications. Methods and Results— Search of our echocardiographic data base between 1993 and 2007 yielded 756 patients with severe AR. with comprehensive clinical data from chart review and mortality data from National Death Index. Mortality was analyzed as a function of MR severity. Effect of AVR and concomitant mitral valve repair were investigated. Patient characteristics were age, 61±17 years; female sex, 41%; and ejection fraction, 54±19%. MR grade ≥2+ was present in 343 (45%) patients: 2+ in 152 (20%), 3+ in 93 (12%), and 4+ in 98 (13%). There was a progressive decrease in survival with each grade of MR ( P <0.0001). Performance of AVR was associated with a better survival in those with 3 or 4+ MR ( P =0.02). In addition, concomitant mitral valve repair in these patients resulted in a better survival (hazard ratio, 0.29; P =0.02). Conclusions— MR is common in patients with severe AR, with 3 or 4+ MR occurring in a quarter of these patients. It is an independent predictor of reduced survival. Performance of AVR and concomitant mitral valve repair is associated with a better survival. Development of MR should serve as an indication for AVR even in asymptomatic patients.

The JUPITER registry: One‐year outcomes of transapical aortic valve implantation using a second generation transcatheter heart valve for aortic regurgitation

“…One should keep in mind that although this patient population is younger and has a lower logEuroSCORE I, it is at higher risk for adverse survival since the response of the left ventricle (LV) after treatment of AR is quantitatively and qualitatively different from AS, mechanistically related to a larger LV with thinner walls and lower ejection fraction . In fact, 50% of patients in our cohort had moderate/severe MR, which is not only an independent predictor of mortality but also weakens the positive effect of TAVR on survival . Of note, significant MR was also frequent in an early experience of first‐generation THV for predominant AR .…”

“…Also logEuroSCORE I was lower but LV function was more frequently impaired (30–50% in 13.3% and <30% in 30.0%). In fact, the most common comorbidity in our cohort was significant MR, which is generally frequent in patients with AR being severe in 25% of patients . In these patients, MR is a reflection of impaired LV function due to volume overload secondary to AR.…”

Almanac 2011: valvular heart disease. The national society journals present selected research that has driven recent advances in clinical cardiology

“…Moreover, performing AVR plus concomitant mitral valve repair was associated with improved survival. These data suggest that the development of MR might provide useful information about the timing of surgery in patients with AR 37. Doctors are often reluctant to offer AVR to patients with severe AR and associated severe LV dysfunction (EF≤35%), yet a recent study has shown that it results in significantly improved 5-year survival rates of 70% as compared with 37% for patients not receiving surgery.…”

Mitral Valve Geometry Changes in Patients with Aortic Regurgitation

“…1,2 The left ventricular (LV) pressure and volume overload caused by significant AR leads to LV dilation, with subsequent changes in papillary muscle position and tethering of the mitral leaflets, which may cause coaptation failure and regurgitation. The prognostic implications of concomitant secondary MR in patients with significant AR are not benign, and it has been shown that mitral valve surgery in addition to aortic valve surgery is associated with better prognosis.…”

“…The prognostic implications of concomitant secondary MR in patients with significant AR are not benign, and it has been shown that mitral valve surgery in addition to aortic valve surgery is associated with better prognosis. 2 However, it remains unclear why some patients with significant AR have concomitant significant secondary MR while other patients do not show MR. 1 A pioneer study using three-dimensional transthoracic echocardiography suggested that patients with significant AR show significantly larger total mitral leaflet area compared with patients without AR, which may reflect mitral leaflet remodeling to prevent failure of mitral leaflet coaptation. 1 However, changes in mitral valve geometry, including the subvalvular apparatus in patients with significant AR, have not been evaluated.…”