Prognostic Significance of Exercise-induced Right Ventricular Dysfunction in Asymptomatic Degenerative Mitral Regurgitation

Kusunose, Kenya; Popović, Zoran B.; Motoki, Hirohiko; Marwick, Thomas H.

doi:10.1161/circimaging.112.000162

Cited by 135 publications

(86 citation statements)

References 33 publications

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“…Therefore, it is not surprising that markers of cardiac dysfunction shown to be associated with poor outcome in mitral regurgitation, such as exercise LV volumes, resting myocardial strain, and resting myocardial strain rate, are also predictors of need for valve surgery in chronic AR. [7][8][9][10][11][12] In contrast, it is unknown whether right ventricular (RV) dysfunction, which seems to be relevant to the outcomes in mitral regurgitation, 13 carries any importance in chronic AR. We have recently developed a framework of assessing incremental value of resting and exercise parameters of both LV and RV function as prognostic parameters of surgical intervention in chronic asymptomatic mitral regurgitation.…”

Section: Clinical Perspective On P 362mentioning

confidence: 99%

Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines

Kusunose

Agarwal

Marwick

et al. 2014

Circ: Cardiovascular Imaging

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Background-The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation remains a matter of debate because of limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation. Methods and Results-Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15 years; 80% male) with isolated moderately severe to severe aortic regurgitation and preserved left ventricular (LV) function (LV ejection fraction >50%, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm or ≤25 mm/m 2 ) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) during 30±21 months. After adjustment for age and sex in a multivariable Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (TAPSE; hazards ratio [HR], 0.48; P=0.001) was associated with valve surgery-free, independent of resting LV strain (HR, 1.63; P=0.005), exercise LV end-diastolic volume (HR, 1.38; P=0.048), and resting RV strain (HR, 1.69; P=0.002 Kusunose et al Exercise Cardiac Dysfunction in AR 353identify the independent and incremental value of LV and RV function at rest and during exercise in predicting future surgical intervention in patients with asymptomatic AR without the need (ie, without class I or IIa indication) for surgery, but with the need for at least annual echocardiographic follow-up. Methods Study SampleBetween January 2006 and January 2012, consecutive asymptomatic patients with moderately severe to severe AR (vena contracta≥0.3 cm and effective regurgitant orifice [ERO] area≥20 mm, 2 regurgitant fraction≥40%, or regurgitant volume≥45mL) 14 were referred for exercise stress echocardiography at the Cleveland Clinic for the assessment of functional impact of AR. Clinical variables were prospectively gathered from the patients and their medical records at the time of the exercise echocardiogram. We selected patients with preserved LV systolic function (LVEF>50%, LV end-diastolic diameter≤70 mm, LV end-systolic diameter≤50 mm, and LV end-systolic diameter/body surface area≤25 mm/m 2 ). Based on an assumed rate of aortic valve surgery of ≈30% during a follow-up period, we anticipated 160 patients would be needed to develop a stable statistical model with 5 predictor variables. 15 The protocol was approved by the Cleveland Clinic Institutional Review Board. Echocardiographic Assessment at Rest and After ExerciseTransthoracic echocardiography was performed by experienced sonographers before and after symptom-limited exercise using a commercially available ultrasound machine (Vivid 7 or Vivid 9, GE Vingmed, Horten, Norway, Sonos 5500 or iE33, Philips, Andover, MA). All patients underwent...

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Section: Clinical Perspective On P 362mentioning

confidence: 99%

Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines

Kusunose

Agarwal

Marwick

et al. 2014

Circ: Cardiovascular Imaging

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“…65 Kusunose et al studied 196 patients with moderate to severe, primary asymptomatic mitral regurgitation and showed that resting left ventricular strain, exercise TAPSE and exercise systolic pulmonary arterial pressure are independent predictors of time to surgery. 66 Exercise-induced right ventricular dysfunction is an independent predictor of worse outcomes in in this patient cohort. Table 3 summarizes the clinical, biologic and echocardiographic predictors of poor outcome in patients with primary mitral regurgitation.…”

Section: Natural History Progression and Predictors Of Outcomes In Mmentioning

confidence: 73%

Primary mitral valve regurgitation: Update and review

Apostolidou

Maslow

Poppas

2017

gcsp

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Mitral regurgitation is the second most common valvular disorder requiring surgical intervention worldwide. This review summarizes the current understanding of primary, degenerative mitral regurgitation with respect to etiology, comprehensive assessment, natural history and management. The new concept of staging of the valvular disorders, newer predictors of adverse and controversy of ‘‘watchful waiting’’ versus ‘‘early surgical intervention’’ for severe, asymptomatic, primary mitral regurgitation are addressed.

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“…Therefore, as in other valvular heart diseases, exercise PH can potentially identify a subset of patients who are at higher risk. 1,2,8,9 In secondary MR, the dynamic increase in MR is a major determinant of the exercise augmentation in SPAP and of exercise PH 3,10 ; it is also involved in the pathogenesis of acute pulmonary edema irrespective of LV function. 11 During exercise, the abrupt increase in MR severity, even if mild, may exceed the level of left atrial compliance and pulmonary vascular recruitment and leads to a significant increase in SPAP up to PH.…”

Section: Discussionmentioning

confidence: 99%

Clinical Significance of Exercise Pulmonary Hypertension in Secondary Mitral Regurgitation

Lancellotti

Magné

Dulgheru

et al. 2015

The American Journal of Cardiology

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In patients with heart failure, exercise echocardiography can help in risk stratification and decision making. The prognostic significance of exercise pulmonary hypertension (PH) in patients with secondary mitral regurgitation (MR) remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR and narrow QRS intervals. From 2005 to 2012, 159 consecutive patients with secondary MR, narrow QRS intervals, left ventricular dysfunction (mean ejection fraction 36 -7%), and measurable systolic pulmonary arterial pressure (SPAP) during exercise echocardiography were included. Resting and exercise PH were defined as SPAP >50 and >60 mm Hg, respectively. Exercise PH was more frequent than resting PH (40% vs 13%, p <0.0001). On multivariate logistic regression, the independent determinants of exercise PH were resting SPAP (p <0.0001), exercise MR severity (p <0.0001), and e 0 -wave velocity (p [ 0.004). The incidence of cardiac events during follow-up was significantly higher in patients with exercise PH compared with those without exercise PH (4 years: 40 -7% vs 20 -5%, p <0.0001). Patients with exercise PH exhibited higher rates of cardiac events and death than those with resting PH. In a multivariate Cox proportional hazards model, exercise PH was independently associated with the occurrence of cardiac events (p <0.0001). In conclusion, in patients with secondary MR, exercise PH is determined mainly by resting SPAP, left ventricular diastolic burden, and exercise MR severity. Exercise PH is a powerful predictor of poor outcomes, with a 5.3-fold increased risk for cardiac-related death during follow-up. These results highlight the added value of exercise echocardiography in secondary MR. Ó 2015 Elsevier Inc. All rights reserved. (Am J Cardiol 2015;-:-e-)In asymptomatic valvular heart disease, exercise pulmonary hypertension (PH) was recently identified by our group as a powerful marker of advanced risk for cardiac events. 1,2 In secondary mitral regurgitation (MR), exercise systolic pulmonary arterial pressure (SPAP) is determined mainly by dynamic MR 3 and is involved in the pathogenesis of acute pulmonary edema. 4 The most recent guidelines recommend mitral valve surgery in asymptomatic patients with preserved left ventricular (LV) ejection fractions and severe primary MR, in the presence of exercise PH (a European Society of Cardiology class IIb indication 5 ). There is no overt indication for surgery in patients with secondary MR and exercise PH, but the European Society of Cardiology guidelines state that exercise PH might be an additional motivation to perform surgery in patients with moderate MR who undergo coronary artery bypass graft surgery (level of evidence C). Nevertheless, the prognostic significance of exercise PH in patients with secondary MR remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR. We hypothesized that exercise PH is an independent predictor of the occurrenc...

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Prognostic Significance of Exercise-induced Right Ventricular Dysfunction in Asymptomatic Degenerative Mitral Regurgitation

Abstract: Conclusions-Exercise-induced

Cited by 135 publications

References 33 publications

Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines

Decision Making in Asymptomatic Aortic Regurgitation in the Era of Guidelines

Primary mitral valve regurgitation: Update and review

Clinical Significance of Exercise Pulmonary Hypertension in Secondary Mitral Regurgitation

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