ABSTRACT
BACKGROUND: Significant secondary mitral regurgitation (SMR) is known to be associated with worse prognosis. However, data focusing specifically on moderate SMR and associated risk factors are lacking. In the present study, clinical and echocardiographic parameters associated with outcomes were evaluated in a large cohort of patients with moderate SMR. METHODS: Patients with moderate SMR were retrospectively included and stratified by New York Heart Association (NYHA) class and specific aetiology (atrial SMR (aSMR) or ventricular SMR (vSMR)) with a further classification of vSMR based on left ventricular ejection fraction (LVEF) ≥40% or <40%. The primary endpoint was all-cause mortality and the secondary endpoint was the composite of all-cause mortality and heart failure (HF) events. RESULTS: Of the total 1061 patients with moderate SMR (age 69±11 years, 59% male) included, 854 (80%) were in NYHA class I-II and 207 (20%) were in NYHA class III-IV. Regarding the aetiology, 352 (33%) had aSMR and 709 (67%) had vSMR, of which 329 (46%) had LVEF ≥40% and 380 (54%) had LVEF <40%. During a median follow-up of 82 (IQR 55-115) months, 397 (37%) died and 539 (51%) patients had HF events or died. On multivariable analysis, NYHA class III-IV (HR 1.578; 95% CI 1.244 to 2.002, p<0.001) and SMR aetiology were independently associated with both endpoints. Specifically, compared to aSMR, vSMR with LVEF ≥40% had a HR of 1.528 (95% CI 1.108 to 2.106, p=0.010) and vSMR with LVEF <40% had a HR of 1.960 (95% CI 1.434 to 2.679, p<0.001). To further support these findings, patients were matched for (1) NYHA class and (2) SMR aetiology by propensity scores including age, sex, diabetes, chronic obstructive pulmonary disease, renal function, left atrial volume index, NYHA class (only for SMR aetiology matching), LVEF, SMR aetiology (only for NYHA class matching), tricuspid regurgitation severity and right ventricular pulmonary artery coupling index. After matching, NYHA class and SMR aetiology remained associated with both outcomes (for both: log rank p<0.050). CONCLUSION: In patients with moderate SMR, distinction in SMR aetiology and assessment of symptoms are important independent determinants of outcome.
ABSTRACT
BACKGROUND: Left atrioventricular coupling index (LACI), an index coupling left atrial to left ventricular (LV) volume at end-diastole, has been shown to be associated with prognosis in different clinical settings. However, the relation between LACI and LV diastolic dysfunction (DD) remains to be established. The aims of the present study were to investigate the association between LACI and LV DD and to assess its prognostic value in patients with heart failure (HF). METHODS: A total of 1,158 patients with HF in stable condition, on optimal medical therapy, were retrospectively analyzed (derivation cohort). Clinical and echocardiographic features were characterized across LACI tertiles. The independent prognostic value of LACI (end point: all-cause death or HF hospitalization) was assessed using Cox regression. Results were validated in an external cohort of 242 patients with HF. RESULTS: In the derivation cohort, the median LACI value was 0.29 (interquartile range, 0.19-0.42). Patients in the third tertile (LACI > 0.36) were older and presented with more advanced HF symptoms. Although the prevalence of grade 1 DD (American Society of Echocardiography/European Association of Cardiovascular Imaging classification) progressively decreased across LACI tertiles, the prevalence of grade 3 DD significantly increased (8%, 23%, and 46%, respectively; P < .0001). A cutoff value of ≥0.26 identified moderate to severe DD with an area under the curve of 0.75. During follow-up (median, 28 months; interquartile range, 11-53 months), 407 patients (35%) reached the end point. On multivariable analysis, LACI was independently associated with outcomes (hazard ratio for a 1-SD increase, 1.16; 95% CI, 1.06-1.28; P = .002), showing incremental predictive value over the DD grading system (net reclassification improvement = 0.150, P < .0001). The prognostic value of LACI was consistent in the external validation cohort. CONCLUSIONS: LACI is associated with DD severity and is an independent predictor of outcomes in patients with HF.