A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation

• Published in: Journal of the American College of Cardiology Vol. 73; no. 20; pp. 2506 - 2517
• Main Authors: Bartko, Philipp E., Arfsten, Henrike, Heitzinger, Gregor, Pavo, Noemi, Toma, Aurel, Strunk, Guido, Hengstenberg, Christian, Hülsmann, Martin, Goliasch, Georg
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 28.05.2019; Elsevier Limited
• Subjects: Aged; Algorithms; Beta blockers; Cardiology; Cardiovascular; Congestive heart failure; Echocardiography, Doppler, Color - methods; Echocardiography, Three-Dimensional - methods; effective regurgitant orifice area; Female; Follow-Up Studies; Heart failure; Heart Failure - diagnosis; Heart Failure - etiology; Heart Failure - physiopathology; heart failure with reduced ejection fraction; Humans; Integrated approach; Laboratories; Male; Middle Aged; mitral insufficiency; Mitral Valve - diagnostic imaging; Mitral Valve Insufficiency - complications; Mitral Valve Insufficiency - diagnosis; Mitral Valve Insufficiency - physiopathology; Mortality; proximal isovelocity surface area; Pulmonary arteries; regurgitant fraction; regurgitant volume; Regurgitation; Risk Factors; Risk groups; secondary mitral regurgitation; Severity of Illness Index; Software; Statistical analysis; Stroke Volume; Thoracic surgery; Ventricular Function, Left - physiology; New York; United States > US; NYHA; ACC; PISA; mitral insufficiency; GDMT; MR; CI; RegFrac; proximal isovelocity surface area; HR; LV; VCW; HFrEF; ASE; RegVol; regurgitant fraction; secondary mitral regurgitation; regurgitant volume; effective regurgitant orifice area; sMR; AHA; heart failure with reduced ejection fraction; EROA; ESC/EACTS; European Society of Cardiology/European Association for Cardio-Thoracic Surgery; New York Heart Association; left ventricular; vena contracta width; mitral regurgitation; American College of Cardiology; guideline-directed medical therapy; American Heart Association; hazard ratio; confidence interval; American Society of Echocardiography
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2019.02.075

Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate. The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy. This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac). Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms. Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading. [Display omitted]