Dynamic handgrip exercise for the evaluation of mitral valve regurgitation: an echocardiographic study to identify exertion induced severe mitral regurgitation

Mhd Nawar Alachkar,Julian Grebe,Mohammad Almalla,Nikolaus Marx,Ertunc Altiok,Michael Frick,Annemarie Kirschfink,Andrea Milzi,Wiebke Moersen,Michael Becker

doi:10.1007/s10554-020-02063-5

Mhd Nawar Alachkar, Julian Grebe + Show 8 more

Open Access

https://doi.org/10.1007/s10554-020-02063-5

Copy DOI

Abstract

Handgrip exercise (HG) has been occasionally used as a stress test in echocardiography. The effect of HG on mitral regurgitation (MR) is not well known. This study aims to evaluate this effect and the possible role of HG in the echocardiographic evaluation of MR. 722 patients with MR were included (18% primary, 82% secondary disease). We calculated effective regurgitant orifice area (EROA) and regurgitant volume (RVOL) at rest and during dynamic HG. Increase in MR was defined as any increase in EROA or RVOL. We analyzed the data to identify possible associations between clinical or echocardiographic parameters and the effect of HG on MR. MR increased during dynamic HG in 390 of 722 patients (54%) (∆EROA = 25%, ∆RVOL = 27%). Increase of regurgitation occurred in 66 of 132 patients with primary MR (50%) and in 324 of 580 patients with secondary MR (55%). This increase was associated with larger baseline EROA and RVOL, but it was independent from other clinical or echocardiographic parameters. In secondary MR, dynamic HG led to a reclassification of regurgitation severity from non-severe at rest to severe MR during HG in 104 of 375 patients (28%). There was a significant association between this upgrade in MR classification and higher New York Heart Association (NYHA) class (OR 1.486, 95%-CI 1.138–1.940, p = 0.004). Dynamic HG exercise increases MR in about half of patients independent of the etiology. Dynamic HG may be used to identify symptomatic patients with non-severe secondary MR at rest but severe MR during exercise.

Highlights

Handgrip exercise (HG) is a simple bedside maneuver to increase the intensity of murmur of mitral regurgitation (MR) during auscultation [1]
Apical 4-chamber view was used for calculation of effective regurgitant orifice area (EROA) and the regurgitant volume (RVOL) using the proximal isovelocity surface area (PISA) method
The major findings of this study are (1) dynamic HG exercise increases MR in about half of patients independent of the etiology, (2) the absolute increase of MR during HG is significantly associated with larger baseline EROA and RVOL in patients with secondary MR and with more dilated left atrial area (LA) in those with primary MR, (3) dynamic HG exercise changes the classification of MR severity from non-severe

Summary

Introduction

Handgrip exercise (HG) is a simple bedside maneuver to increase the intensity of murmur of mitral regurgitation (MR) during auscultation [1]. HG has been used in combination with dobutamine stress echocardiography to identify patients with MR who would probably benefit from percutaneous mitral valve repair [4]. In patients with heart failure, MR is associated with an adverse prognosis [7]. Exercise echocardiography has been described to improve assessment of MR severity [9, 10]. It may be used to predict outcome in patients with heart failure and mitral regurgitation, as a large exercise-induced increase in MR is associated with higher morbidity and mortality [11].

Objectives

Methods

Discussion

Conclusion