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Disproportionate Functional Mitral Regurgitation: clinical validation of a new conceptual framework
Session:
Sessão de Comunicações Orais - Doença Valvular
Speaker:
Pedro M. Lopes
Congress:
CPC 2020
Topic:
B. Imaging
Theme:
03. Imaging
Subtheme:
03.1 Echocardiography
Session Type:
Comunicações Orais
FP Number:
---
Authors:
Pedro M. Lopes; Francisco Albuquerque; Pedro Freitas; Francisco Fernandes Gama; Bruno ML Rocha; Gonçalo Lopes Da Cunha; Eduarda Horta; Carla Reis; António Miguel Ferreira; João Abecasis; Marisa Trabulo; Manuel Canada; Regina Ribeiras; Miguel Mendes; Maria João Andrade
Abstract
<p><strong>Background: </strong>Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR.</p> <p> </p> <p><strong>Methods: </strong>Patients with at least mild FMR and reduced LVEF (<50%) who underwent transthoracic echocardiography between 2010 and 2014 were retrospectively identified in our laboratory database. Optimal medical therapy (including cardiac resynchronization when indicated) for ≥3 months was a prerequisite for inclusion. Hemodynamically significant FMR was defined as regurgitant fraction >50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the <em>haemodynamic </em><em>burden</em> of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF <30% and 30–49%).</p> <p> </p> <p><strong>Results:</strong> A total of 289 patients (median age 69 years [IQR 60-77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm<sup>2</sup> (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: <10mL: 41%; 10-20mL: 18%; 20-30mL: 15% and >30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p<0.001).</p> <p>During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF <30% subgroup, age (HR 1.05 per year [1.02–1.08]; p<0.001), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.042) and TAPSE (HR 0.92 per mm [0.86–0.99]; p=0.030) were independent predictors of mortality. In the LVEF 30–49% subgroup, age (HR 1.05 per year [1.02–1.08]; p=0.003), LVEF (HR 0.94 per 1% [0.89–0.99]; p=0.020) and disproportionate FMR (HR 1.02 per mL [1.01–1.03]; p=0.01) were independently associated with increased mortality.</p> <p> </p> <p><strong>Conclusions: </strong>Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF<30%, where the degree of biventricular dysfunction seems to outweigh all other echocardiographic parameters, leaving FMR as a bystander.</p>
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