Abstract
Background: The impact of percutaneous mitral valve repair (PMVr) on long-term prognosis in patients with functional mitral regurgitation (FMR) is still unclear. Recently, a new conceptual framework classifying FMR as proportionate (P-MR) and disproportionate (D-MR) was proposed, according to the effective regurgitant orifice area/left ventricular end-diastolic volume (EROA/LVEDV) ratio. The aim was to assess its possible influence on PMVr efficacy. Methods: A total of 56 patients were enrolled. MV annulus, LV volumes and function were assessed. Global longitudinal strain (GLS) was also calculated. Patients were divided into two groups, according to the EROA/LVEDV ratio. Echocardiographic follow-up was performed after 6 months, and adverse events were collected after 12 months. Results: D-MR patients (n = 28, 50%) had a significantly more elliptical MV annulus (p = 0.048), lower tenting volume (p = 0.01), higher LV ejection fraction (LVEF: 32 ± 7 vs. 26 ± 5%, p = 0.003), lower LVEDV, LV end-systolic volume (LVESV) and mass (LVEDV/i: 80 ± 20 vs. 126 ± 27 mL, p = 0.001; LVESV/i: 60 ± 20 vs. 94 ± 23 mL, p < 0.001; LV mass: 249 ± 63 vs. 301 ± 69 gr, p = 0.035). GLS was more impaired in P-MR (p = 0.048). After 6 months, P-MR patients showed a higher rate of MR recurrence. After 12 months, the rate of CV death and rehospitalization due to HF was significantly higher in P-MR patients (46% vs. 7%, p < 0.001). P-MR status was strongly associated with CV death/rehospitalization (HR = 3.4, CI 95% = 1.3–8.6, p = 0.009). Conclusions: Patients with P-MR seem to have worse outcomes after PVMr than D-MR patients. Our study confirms the importance of the EROA/LVEDV ratio in defining different subsets of FMR based on the anatomical characteristic of MV and LV.
Highlights
Functional mitral regurgitation (FMR) occurs in patients with left ventricular (LV) dysfunction in the absence of a significant structural abnormality of mitral valve leaflets [1]
Grayburn et al [11] proposed a conceptual framework that explains the different outcomes in COAPT and Mitra-FR, depending on whether the effective regurgitant orifice area (EROA) was proportionate (P-MR) to the left ventricular end-diastolic volume (LVEDV) or not
The present study confirmed that: (1) the model of MR characterization on the basis of the EROA/LVEDV ratio [11,12,13,14,15,16] is applicable in clinical practice; (2) P-MR patients had higher LV volumes, less elliptical MV annulus and higher tenting volume as assessed by 3D echo; (3) P-MR patients had worse prognosis in terms of CV death and heart failure (HF) hospitalization within 1 year along with a lower rate of MV repair durability; (4) no other relevant clinical and echocardiographic features demonstrated association with outcomes over P-MR status
Summary
Functional mitral regurgitation (FMR) occurs in patients with left ventricular (LV) dysfunction in the absence of a significant structural abnormality of mitral valve leaflets [1]. Grayburn et al [11] proposed a conceptual framework that explains the different outcomes in COAPT and Mitra-FR, depending on whether the effective regurgitant orifice area (EROA) was proportionate (P-MR) to the left ventricular end-diastolic volume (LVEDV) or not (disproportionate or D-MR). In P-MR, the mechanism of FMR can be explained by LV dilation alone, while in D-MR the degree of MR is more often due to focal regional wall motion abnormalities or dyssynchrony, factors that are not likely to respond only to medical therapy This hypothesis helps to explain differences between Mitra-FR and COAPT trials, it has not been evaluated prospectively in patients. A new conceptual framework classifying FMR as proportionate (P-MR) and disproportionate (D-MR) was proposed, according to the effective regurgitant orifice area/left ventricular end-diastolic volume (EROA/LVEDV) ratio. Our study confirms the importance of the EROA/LVEDV ratio in defining different subsets of FMR based on the anatomical characteristic of MV and LV
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