Asymptomatic Severe Mitral Regurgitation Research Articles

Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation

Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation

977 Quantitative assessment of myocardial contractile reserve during exercise in patients with mitral valve prolapse

Background: Although the actual trends is toward early surgery in patients with asymptomatic severe organic mitral regurgitation (MR), some of them might already have latent left ventricular (LV) dysfunction. This study sought to examine whether tissue Doppler imaging measurement of longitudinal function could be used to identify contractile reserve (CR) during exercise in NYHA I-II patients with MR due to mitral valve prolapse. Methods: Forty-seven patients underwent quantitative off-line assessment of longitudinal function by averaging peak mitral annular velocities (PSv) obtained at rest and during semi-supine exercise test. Results: During test, CR defined by 34% improvement in ejection fraction was present in 25 patients. As compared to patients with CR, the degree of MR at rest (effective regurgitant orifice (ERO): 43±18 vs 24±14 mm2, p=0.0048) and at peak exercise (ERO 46±22 vs 23±19 mm2, p=0.0049) was greater in the absence of CR whereas ejection fraction was similar (69±6 vs 66±6%, p=ns). The increase in PSv (11±1.9 vs 8±2.5 cm/s, p=0.00029) and changes in LV end-systolic volume (-14±7 vs 4.4±12 ml p=0.0029) during exercise were higher in the CR group. In multivariate analysis, exercise-induced changes in LV end-systolic volume and in PSv independently predicted the presence of CR. An increase in PSv by 32 cm/s yielded a sensitivity of 88% and a specificity of 82% to identify positive CR. Conclusions: Latent LV dysfunction in patients with mitral valve prolapse could be reliably identified using tissue Doppler imaging.

Surgery for Asymptomatic Severe Mitral Regurgitation in the Elderly

Cardiovascular disease is the major cause of death in subjects >75 years of age, a healthcare problem that will increase as the population continues to age. In the United States, the predicted population >75 years of age will exceed 50 million by the year 2038. Epidemiological studies have shown that the prevalence of mitral regurgitation (MR) also increases progressively with age; thus, MR is a common and growing problem in the elderly.1 The most frequently encountered types of MR in the elderly are degenerative mitral valve disease, which results from primary floppy, myxomatous valves with prolapsing or flail leaflets and calcified mitral annulus, and ischemic MR (IMR), now that rheumatic mitral valve disease has declined and endocarditis remains comparatively rare. Article p 265 Although there are American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the optimal management of a broad spectrum of patients with severe MR,2 attention has not focused specifically on the elderly, in whom the condition predominates. In addition, operative mortality is increased in the elderly by major comorbidities that include coronary artery disease, cerebrovascular disease, heart failure, atrial fibrillation, and renal insufficiency. Furthermore, little is known regarding the difference in life expectancy and risk of adverse events in elderly patients with severe MR undergoing successful mitral valve surgery versus those who decline or are denied surgical intervention. A delicate balance must be struck in optimally managing elderly patients with severe MR that not only favors symptomatic benefit over perioperative risk of an adverse clinical outcome, but also improves long-term outcome with regard to morbidity and mortality. Over the past 2 decades, surgical strategies in the treatment of MR have changed from routine mitral valve replacement to mitral valve repair. Because the surgeons’ understanding of normal mitral valve functional anatomy has improved, largely because of …

Issue Highlights

HomeCirculationVol. 113, No. 18Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published9 May 2006https://doi.org/10.1161/circ.113.18.2165Circulation. 2006;113:2165CHARACTERISTICS AND BASELINE CLINICAL PREDICTORS OF FUTURE FATAL VERSUS NONFATAL CORONARY HEART DISEASE EVENTS IN OLDER ADULTS: THE CARDIOVASCULAR HEALTH STUDY, by Pearte et al.The aging of the population has brought increased focus onto the high morbidity and mortality of coronary heart disease (CHD) in the elderly. Pearte and colleagues examined the predictors and the temporal trends in CHD mortality in community-dwelling elderly adults participating in the Cardiovascular Heath Study. They observed that traditional risk factors and indicators of subclinical disease assessed before CHD event predicted an increased risk of CHD fatality. For instance, antecedent heart failure regardless of left ventricular systolic function conferred a 3-fold increased risk of death. The authors noted that although case-fatality decreased slightly over time, CHD remains lethal for almost one third of elderly individuals suffering a CHD event. In the era of personalized medicine, the authors argue that further efforts should be directed toward identifying effective strategies to prevent poor outcomes in high-risk elderly patients with CHD events. See p 2177.ROLE OF DIURETICS IN THE PREVENTION OF HEART FAILURE: THE ANTIHYPERTENSIVE AND LIPID-LOWERING TREATMENT TO PREVENT HEART ATTACK TRIAL, by Davis et al.High blood pressure is a key risk factor for congestive heart failure (CHF). The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized controlled comparison of chlorthalidone, amlodipine, and lisinopril (representing diuretics, calcium channel blockers, and angiotensin-converting enzyme inhibitors) for prevention of cardiovascular disease events in hypertensive patients. In this issue of Circulation, Davis and colleagues report on the relative effects of these 3 antihypertensive agents on rates of hospitalized/fatal CHF in ALLHAT. The authors observed that comparative risks for CHF in the 3 arms varied over time. In the first year of the trial, patients in the amlodipine and lisinopril arms experienced a 2-fold greater risk of CHF compared to those in the chlorthalidone arm. Beyond the first year, CHF risks were comparable for the chlorthalidone and lisinopril arms, but higher in the amlodipine arm. These differences in CHF rates in the 3 treatment arms were not explained by prior medication use or by the blood pressure level at baseline or on follow-up. These observations suggest that diuretics may be superior to calcium channel blockers for the prevention of CHF in hypertensive patients. See p 2201.OUTCOME OF WATCHFUL WAITING IN ASYMPTOMATIC SEVERE MITRAL REGURGITATION, by Rosenhek et al.Timing of surgery in patients with mitral regurgitation remains a challenge. Several recent studies have recommended liberalization of indications, particularly when mitral valve repair is feasible. Current published guidelines recommend watchful waiting, but the safety of this approach has not been prospectively evaluated. In this week’s journal, Rosenhek et al describe 132 consecutive asymptomatic patients with severe mitral regurgitation followed up for an average of just over 5 years. Patients were followed up with careful serial clinical evaluation and echocardiograms and were referred for surgery when they met guideline-based criteria. Overall survival was not different from expected survival. During follow-up, 38 patients met the criteria for surgery. Postoperative outcome was good in terms of survival, symptoms, and postoperative left ventricular function. This important prospective study provides further support for current guidelines that recommend “watchful waiting” for asymptomatic patients with severe mitral regurgitation. In addition, the study emphasizes the importance of careful clinical and echocardiographic vigilance in this setting. See p 2238.Visit http://circ.ahajournals.org:Images in Cardiovascular MedicineCompression of the Pulmonary Vein After Right-Sided Pneumonectomy. See p e743.Balloon Valvuloplasty of a Stenosed Bioprosthetic Tricuspid Valve. See p e745.Percutaneous Closure of a Left Ventricular Free-Wall Rupture Site. See p e748. Download figureDownload PowerPointBook ReviewThe Adrenergic Receptors in the 21st Century. See p e750.CorrespondenceSee p e751. Previous Back to top Next FiguresReferencesRelatedDetails May 9, 2006Vol 113, Issue 18 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.113.18.2165 Originally publishedMay 9, 2006 PDF download Advertisement

Outcome of Watchful Waiting in Asymptomatic Severe Mitral Regurgitation

The management of asymptomatic severe mitral regurgitation remains controversial. The aim of this study was to evaluate the outcome of a watchful waiting strategy in which patients are referred to surgery when symptoms occur or when asymptomatic patients develop left ventricular (LV) enlargement, LV dysfunction, pulmonary hypertension, or recurrent atrial fibrillation. A total of 132 consecutive asymptomatic patients (age 55+/-15 years, 49 female) with severe degenerative mitral regurgitation (flail leaflet or valve prolapse) were prospectively followed up for 62+/-26 months. Patients underwent serial clinical and echocardiographic examinations and were referred for surgery when the criteria mentioned above were fulfilled. Overall survival was not statistically different from expected survival either in the total group or in the subgroup of patients with flail leaflet. Eight deaths were observed. Thirty-eight patients developed criteria for surgery (symptoms, 24; LV criteria, 9; pulmonary hypertension or atrial fibrillation, 5). Survival free of any indication for surgery was 92+/-2% at 2 years, 78+/-4% at 4 years, 65+/-5% at 6 years, and 55+/-6% at 8 years. Patients with flail leaflet tended to develop criteria for surgery slightly but not significantly earlier. There was no operative mortality. Postoperative outcome was good with regard to survival, symptomatic status, and postoperative LV function. Asymptomatic patients with severe degenerative mitral regurgitation can be safely followed up until either symptoms occur or currently recommended cutoff values for LV size, LV function, or pulmonary hypertension are reached. This management strategy is associated with good perioperative and postoperative outcome but requires careful follow-up.

Functional and Prognostic Implications of Left Ventricular Contractile Reserve in Patients With Asymptomatic Severe Mitral Regurgitation

Functional and Prognostic Implications of Left Ventricular Contractile Reserve in Patients With Asymptomatic Severe Mitral Regurgitation

Prediction of subclinical left ventricular dysfunction with strain rate imaging in patients with asymptomatic severe mitral regurgitation

This study sought the ability of strain rate imaging to detect subclinical left ventricular dysfunction, as evidenced by reduced contractile reserve (CR) in 32 asymptomatic patients with isolated severe mitral regurgitation. Compared with CR- patients (n = 10), CR+ patients (n = 22) had significantly higher end-systolic strain and peak systolic strain rate, but these parameters were not significantly different between CR+ patients and matched normal controls.

Natural history of asymptomatic severe mitral regurgitation: Dissociation of symptom development and ventricular performance?

Natural history of asymptomatic severe mitral regurgitation: Dissociation of symptom development and ventricular performance?