Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation

Enríquez-Sarano, Maurice; Avierinos, Jean-François; Messika–Zeitoun, David; Détaint, Delphine; Capps, Maryann; Nkomo, Vuyisile T.; Scott, Christopher G.; Schaff, Hartzell V.; Tajik, A. Jamil

doi:10.1056/nejmoa041451

Cited by 947 publications

(313 citation statements)

References 37 publications

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“…MR by guest on May 7, 2018 http://circimaging.ahajournals.org/ Downloaded from TTE and EVAR is common, and most patients are asymptomatic at diagnosis, which was previously believed to be a benign finding. 26 However, Enriquez-Sarano et al 27 demonstrated that asymptomatic MR is a powerful predictor of death from any cause, death from cardiac causes, and cardiac events. The management of asymptomatic patients with valve disease is an important medical problem, 28 and the results of our study suggest that quantitative assessment of MR severity permits risk stratification of patients undergoing EVAR.…”

Section: Discussionmentioning

confidence: 99%

Transthoracic Echocardiography Provides Important Long-Term Prognostic Information in Selected Patients Undergoing Endovascular Abdominal Aortic Repair

O’Driscoll

Bahia

Gravina

et al. 2016

Circ: Cardiovascular Imaging

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Background— The value of performing transthoracic echocardiography (TTE) as part of the clinical assessment of patients awaiting endovascular repair of the abdominal aorta is little evaluated. We aimed to estimate the prognostic importance of information derived from TTE on long-term all-cause mortality in a selected group of patients undergoing endovascular aneurysm repair. Methods and Results— This was a retrospective cohort study of 273 consecutive patients selected for endovascular aneurysm repair. All patients included in the analysis underwent TTE before their procedure. Multivariable Cox regression analysis was used to estimate the effect of TTE measures on all-cause mortality. Over a mean follow-up of 3.2±1.5 years, there were 78 deaths with a mean time to death of 1.28±1.16 years. A greater tubular ascending aorta (hazard ratio [HR] 5.6, 95% confidence interval [CI] 2.77–11.33), presence of mitral regurgitation (HR 8.13, 95% CI 4.09–12.16), lower left ventricular ejection fraction (HR 0.96, 95% CI 0.93–0.98), younger age (HR 0.97, 95% CI 0.95–0.99), and presence of diabetes mellitus (HR 1.46, 95% CI 1.24–1.89) were predictors of all-cause mortality. Conclusions— Echocardiography provides important long-term prognostic information in patients undergoing endovascular aneurysm repair. These TTE indices were more important at predicting outcome than standard conventional risk factors in this patient group. A greater tubular ascending aorta, presence of mitral regurgitation, reduced left ventricular ejection fraction, younger age, and diabetes mellitus were independently associated with long-term mortality.

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Section: Discussionmentioning

confidence: 99%

Transthoracic Echocardiography Provides Important Long-Term Prognostic Information in Selected Patients Undergoing Endovascular Abdominal Aortic Repair

O’Driscoll

Bahia

Gravina

et al. 2016

Circ: Cardiovascular Imaging

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“…The Mayo Clinic study 11 showed a significant association of quantitative echocardiographic grading with prognosis (both mortality and cardiac events), although this study did not specifically assess the progression to cardiac surgery, which was not included as a cardiac event. Subjects with moderate MR also had a significant cardiac event rate (40%, versus 62% for severe MR), which suggests a weaker ability of quantitative echocardiography to identify patients at risk of events, and highlights the difficulty in separating moderate and severe MR in some patients, the very group examined in our study.…”

Section: Previous Studies Of Outcome In Mrmentioning

confidence: 99%

“…This can be achieved with echocardiography, 10 although echocardiographic quantification is used primarily to aid grading as mild, moderate, and severe regurgitation 10 rather than identifying patients for surgery. One important study has shown an association of quantitative echocardiographic MR grading with mortality in medically treated patients, 11 but this study did not address the identification of patients for surgery.…”

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confidence: 99%

Determination of Clinical Outcome in Mitral Regurgitation With Cardiovascular Magnetic Resonance Quantification

et al. 2016

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Background— Surgery for severe mitral regurgitation is indicated if symptoms or left ventricular dilation or dysfunction occur. However, prognosis is already reduced by this stage, and earlier surgery on asymptomatic patients has been advocated if valve repair is likely, but identifying suitable patients for early surgery is difficult. Quantifying the regurgitation may help, but evidence for its link with outcome is limited. Cardiovascular magnetic resonance (CMR) can accurately quantify mitral regurgitation, and we examined whether this was associated with the future need for surgery. Methods and Results— One hundred nine asymptomatic patients with echocardiographic moderate or severe mitral regurgitation had baseline CMR scans and were followed up for up to 8 years (mean, 2.5±1.9 years). CMR quantification accurately identified patients who progressed to symptoms or other indications for surgery: 91% of subjects with regurgitant volume ≤55 mL survived to 5 years without surgery compared with only 21% with regurgitant volume >55 mL ( P <0.0001). A similar separation was observed for regurgitant fraction ≤40% and >40%. CMR-derived end-diastolic volume index showed a weaker association with outcome (proportions surviving without surgery at 5 years, 90% for left ventricular end-diastolic volume index <100 mL/m 2 versus 48% for ≥100 mL/m 2 ) and added little to the discriminatory power of regurgitant fraction/volume alone. Conclusions— CMR quantification of mitral regurgitation was associated with the development of symptoms or other indications for surgery and showed better discriminatory ability than the reference-standard CMR-derived ventricular volumes. CMR may be able to identify appropriate patients for early surgery, with the potential to change clinical practice, although the clinical benefits of early surgery require confirmation in a clinical trial.

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“…In addition, numerous cardiac disease states are defined by phasic adaptations in myocardial structural and function. 11,12 Whether the EICR that occurs among competitive athletes develops in a phasic sequence remains unknown because of the lack of long-term longitudinal data. Determining the time course of EICR represents a critical step in further defining the myocardial response Background-Contemporary understanding of exercise-induced cardiac remodeling is based on cross-sectional data and relatively short duration longitudinal studies.…”

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confidence: 99%

Exercise-Induced Left Ventricular Remodeling Among Competitive Athletes

Weiner

DeLuca

Wang

et al. 2015

Circ: Cardiovascular Imaging

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E xercise-induced cardiac remodeling (EICR) refers to changes in cardiac structure and function that occur in response to exercise training. Numerous structural aspects of EICR (ie, athlete's heart) including ventricular chamber enlargement 1 and hypertrophy 2 have been described, and several key determinants of the EICR process including age, 3 sex, 4 ethnicity, 5 and sporting discipline 6,7 have been established. However, contemporary understanding of EICR is based largely on cross-sectional data derived from competitive athletes and instructive but relatively short duration longitudinal studies of recreational exercisers. 8,9 Therefore, the temporal progression of EICR among competitive athletes remains incompletely understood. See Clincial Perspective See Editorial by D'Silva and SharmaThe myocardial response to hemodynamic perturbation occurs in discrete phases in numerous settings. Specifically, physiological remodeling after 12 months of exercise training in previously sedentary people 9 and cardiac adaptations during pregnancy 10 occurs in different stages. In addition, numerous cardiac disease states are defined by phasic adaptations in myocardial structural and function. 11,12 Whether the EICR that occurs among competitive athletes develops in a phasic sequence remains unknown because of the lack of long-term longitudinal data. Determining the time course of EICR represents a critical step in further defining the myocardial response Background-Contemporary understanding of exercise-induced cardiac remodeling is based on cross-sectional data and relatively short duration longitudinal studies. Temporal progression of exercise-induced cardiac remodeling remains incompletely understood. Methods and Results-A longitudinal repeated-measures study design using 2-dimensional and speckle-tracking echocardiography was used to examine acute augmentation phase (AAP; 90 days) and more extended chronic maintenance phase (39 months) left ventricular (LV) structural and functional adaptations to endurance exercise training among competitive male rowers (n=12; age 18.6±0.5 years). LV mass was within normal limits at baseline (93±9 g/ m 2 ), increased after AAP (105±7 g/m 2 ; P=0.001), and further increased after chronic maintenance phase (113±10 g/m 2 ; P<0.001 for comparison to post-AAP). AAP LV hypertrophy was driven by LV dilation (ΔLV end-diastolic volume, 9±3 mL/m 2 ; P=0.004) with stable LV wall thickness (ΔLV wall thickness, 0.3±0.1 mm; P=0.63). In contrast, chronic maintenance phase LV hypertrophy was attributable to LV wall thickening (Δ LV wall thickness, 1.1±0.4 mm; P=0.004) with stable LV chamber volumes (ΔLV end-diastolic volume, 1±1 mL/m 2 ; P=0.48). Early diastolic peak tissue velocity increased during AAP (−11.7±1.9 versus −13.6±1.3 cm/s; P<0.001) and remained similarly increased after chronic maintenance phase. Conclusions-In a small sample of competitive endurance athletes, exercise-induced cardiac remodeling follows a phasic response with increases in LV chamber size, early diastolic function, and sy...

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Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation

Abstract: Quantitative grading of mitral regurgitation is a powerful predictor of the clinical outcome of asymptomatic mitral regurgitation. Patients with an effective regurgitant orifice of at least 40 mm2 should promptly be considered for cardiac surgery.

Cited by 947 publications

References 37 publications

Transthoracic Echocardiography Provides Important Long-Term Prognostic Information in Selected Patients Undergoing Endovascular Abdominal Aortic Repair

Transthoracic Echocardiography Provides Important Long-Term Prognostic Information in Selected Patients Undergoing Endovascular Abdominal Aortic Repair

Determination of Clinical Outcome in Mitral Regurgitation With Cardiovascular Magnetic Resonance Quantification

Exercise-Induced Left Ventricular Remodeling Among Competitive Athletes

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