Prognostic implications of functional mitral regurgitation according to the severity of the underlying chronic heart failure: a long-term outcome study.

AIMS: To examine the independent prognostic role of functional mitral regurgitation (FMR) and its impact across the severity of chronic heart failure (CHF) in a large population of outpatients with systolic CHF followed at two multidisciplinary clinics. METHODS AND RESULTS: Echocardiography was performed upon enrolment in 469 CHF patients. Follow-up for death and heart transplant was updated on January 2007. Five-year transplant-free survival was 82.7% in patients with no or Grade I FMR, 64.4% in Grade II, 58.5% in Grade III, and 46.5% in Grade IV (P < 0.0001). There was a strong graded association between FMR and the long-term risk of death and heart transplant, which remained significant after multivariable adjustment (P = 0.0003). The association between FMR and events was strong and independent in patients with less severe symptoms and in those at lower overall risk based on a propensity score analysis, while it was not significant in patients with more advanced CHF or in the high-risk subgroup (P < 0.0001 for interactions). CONCLUSION: This study clarifies previous apparently discrepant results by demonstrating that FMR is an independent determinant of death and heart transplantation only in less severe CHF and in patients with a lower risk profile. This finding indicates that FMR plays a major role in the early phase of CHF, suggesting that this should be the focus of strategies attempting to reduce it.

Left atrium reclassified: application of the American Society of Echocardiography/European Society of Cardiology cutoffs to unselected outpatients referred to the echocardiography laboratory.

OBJECTIVES: We sought to determine whether categorization of abnormal left atrial (LA) size based on volumes indexed to body surface area (LAVi) results in reclassification of LA dilatation if the classic antero-posterior diameter (LAd) was measured. The American Society of Echocardiography/European Society of Cardiology recommended LAVi over linear measurements and recently published cutoffs to qualify LA dilatation. However, many laboratories continue to use the LAd because it appears easier to measure. METHODS: Unselected adult outpatients referred to the echocardiography laboratory for any indication in the period March 2005 to January 2006 prospectively underwent standard Doppler echocardiography, including real-time measurement of LAd and LAVi. RESULTS: We enrolled 578 patients (mean age 66 +/- 14 years, 56% women). There was a good positive linear correlation between LAd and LAVi (r = 0.686, P < .0001). When the published cutoffs for LA enlargement were used, 49.0% of patients were classified as having abnormal LA by LAd and 76.3% by LAVi (P < .001). Of the 295 who had normal LA by LAd, 58.6% patients had abnormal LAVi. Conversely, of the 283 with abnormal LAd, almost all patients (94.7%) had abnormal LAVi. The proportion of overall agreement was 67.5% (kappa = 0.357, P < .001). CONCLUSION: Assessment of LA size by LAVi allows identification of patients with enlarged atria that would have been missed if classified by antero-posterior diameters, especially when cutoffs are applied.

Evidence of reverse remodeling after long-term biventricular stimulation for resynchronization in patients with wide QRS selected on the basis of echocardiographic electromechanical delays.

BACKGROUND: There is increasing evidence that cardiac resynchronization therapy (CRT) may trigger an inverse remodeling process leading to decreased left ventricular (LV) volumes in patients with heart failure and wide QRS. However, it is still important to simplify patient selection and achieve a widely applicable parameter to better stratify patients who are candidates for CRT. METHODS: Eighteen patients (13 males, 5 females, mean age 67.5 +/- 7.2 years) with advanced heart failure due to ischemic (n = 12) or idiopathic dilated cardiomyopathy (n = 6) and complete left bundle branch block received biventricular pacing. The patients were considered eligible in the presence of echocardiographic evidence of intra- and interventricular asynchrony, defined on the basis of LV electromechanical delay. Investigations were performed before pacemaker implantation (at baseline), the day after, and 3 and 6 months later. RESULTS: Two patients died before the first outpatient examination. There were 15 (83%) responders to reverse remodeling among the remainder. In the overall population, there was a significant and progressive improvement in LV sphericity indexes, ejection fraction, mitral regurgitation area and LV volumes (p < 0.001). The improvement in the interventricular mechanical delay after CRT was significantly correlated with the decrease in LV end-systolic volume (r2 = 0.2558, p = 0.04). CONCLUSIONS: CRT reduces LV volumes in patients with advanced heart failure, complete left bundle branch block and detailed documentation of ventricular asynchrony prior to therapeutic pacing. Broadly applicable Doppler echocardiographic measures may increase the specificity of the long-term response to CRT in terms of LV performance.