[en] Background-In the post-myocardial infarction phase, mortality risk is related to the severity of mitral regurgitation (MR). Ischemic MR is a dynamic condition that can be studied during exercise. Whether the assessment of exercise-induced changes in the degree of MR provides prognostic information is unknown. Methods and Results-Ninety-eight consecutive patients with chronic ischemic left ventricular dysfunction and at least mild MR who prospectively underwent quantitative measurement of the regurgitant volume and the effective regurgitant orifice (ERO) of MR at rest and during semisupine exercise test were followed up for 19+/-8 months. The 16 patients who underwent surgery were censored at the time of operation. Of the 82 patients who were medically treated, 9 (11%) died. No clinical data demonstrated a distinction between survivors and nonsurvivors. By multivariate Cox regression analysis, independent predictors of cardiac death were an increase in ERO by greater than or equal to13 mm(2) (P=0.0045) during exercise, an ERO >20 mm(2) at rest (P=0.01), and a shorter mitral deceleration time (P=0.044). Half of the patients with exercise-induced significant increases in MR who died had moderate MR at rest. In contrast, none of the 14 patients with a decrease in MR at exercise displayed cardiac death. Conclusions-In patients with ischemic MR and left ventricular dysfunction, quantitative assessment of exercise-induced changes in the degree of MR provides independent prognostic information. Significant exercise-induced increases in MR unmask patients at high risk of poor outcome.
Disciplines :
Cardiovascular & respiratory systems Hematology
Author, co-author :
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Département des sciences cliniques
Barzilai B, Davis VG, Stone PH, et al. Prognostic significance of mitral regurgitation in acute myocardial infarction. Am J Cardiol. 1990;65:1169-1175.
Feinberg MA, Schwammenthal E, Shlizerman L, et al. Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction. Am J Cardiol. 2000;86:903-907.
Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction: Survival And Ventricular Enlargement Investigators. Circulation. 1997;96:827-833.
Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation. 2001;103:1759-1764.
Lewis JF, Webber JD, Sutton LL, et al. Discordance in the degree of right and left ventricular dilatation in patients with dilated cardiomyopathy: recognition and clinical implications. J Am Coll Cardiol. 1993;21:649-654.
Lebrun F, Lancellotti P, Piérard LA. Quantitation of functional mitral regurgitation during bicycle exercise in patients with heart failure. J Am Coll Cardiol. 2001;38:1685-1692.
Enriquez-Sarano M, Rossi A, Seward JB, et al. Determinants of pulmonary hypertension in left ventricular dysfunction. J Am Coll Cardiol. 1997;29:153-159.
Rihal CS, Nishimura RA, Hatle LK, et al. Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy: relation to symptoms and prognosis. Circulation. 1994;90:2772-2779.
Pouleur HG, Konstam MA, Udelson JE, et al. Changes in ventricular volume, wall thickness and wall stress during progression of left ventricular dysfunction: the SOLVD Investigators. J Am Coll Cardiol. 1993;22:43A-48A.
Conti JB, Mills RM. Mitral regurgitation and death while awaiting cardiac transplantation. Am J Cardiol. 1993;71:617-618.
Stein KM, Borer JS, Hochreiter C, et al. Prognostic value and physiological correlates of heart rate variability in chronic severe mitral regurgitation. Circulation. 1993;88:127-135.
Martinez-Rubio A, Schwammenthal Y, Schwammenthal E, et al. Patients with valvular heart disease presenting with sustained ventricular tachyarrhythmias or syncope: results of, programmed ventricular stimulation and long-term follow-up. Circulation. 1997;96:500-508.
Duren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic mitral valve prolapse in 300 patients: a prospective study. J Am Coll Cardiol. 1988;11:42-47.
Delahaye MJ, Gare JP, Viguier E, et al. Natural history of severe mitral regurgitation. Eur Heart J. 1991;12:5-9.
Dujardin KS, Enriquez-Sarano M, Bailey KR, et al. Grading of mitral regurgitation by quantitative Doppler echocardiography: calibration by left ventricular angiography in routine clinical practice. Circulation. 1997;96:3409-3415.
Enriquez-Sarano M, Seward JB, Bailey KR, et al. Effective regurgitant orifice area: a noninvasive Doppler development of an old hemodynamic concept. J Am Coll Cardiol. 1994;23:443-451.
Cohen-Solal A, Tabet JY, Logeart D, et al. A noninvasively determined surrogate of cardiac power at peak exercise is a powerful prognostic factor in chronic heart failure. Eur Heart J. 2002:23:806-814.