Prognostic Role of Secondary Mitral Regurgitation in Patients with Aortic Valve Stenosis under Medical Follow-up
Giovanni Benfari1, Caterina Maffeis1, Giulia Vinco1, Francesco Onorati2, Riccardo M. Inciardi1, Stefano Nistri3, Flavio L. Ribichini1, Andrea Rossi1.
1Section of Cardiology, Department of Medicine, Verona, Italy, 2Section of Cardiac Surgery, Department of Surgery, Verona, Italy, 3CMSR Veneto Medica, Altavilla Vicentina, Vicenza, Italy.
OBJECTIVE: Secondary Mitral Regurgitation (sMR) is frequent in patients with significant aortic valve stenosis (AS), but it's rarely considered of clinical relevance since the regurgitation is often less than severe. We hypothesize that sMR is associated with heart failure development in patients with significant AS under medical follow-up.
METHODS: Patients with AS referred to the echocardiographic laboratory of Verona were included. Exclusion criteria were: reduced left ventricular ejection fraction; organic mitral valve disease or mitral valve prosthesis. Cardiovascular (CV) events included hospitalization for heart failure and CV death; aortic valve surgery/transcatheter valve intervention (TAVI) was considered a censoring event.
RESULTS: The study population consists of 68 patients (age 77±8 years, 59% female). AS was moderate in 19 (28%) patients and severe in 49 (72%) (mean gradient 38±12 mmHg, aortic valve area [AVA] 0.92±0.32 cm2). Overall, 42 patients (62%) had sMR (ERO 9.8±6.8 mm2). Patients with sMR were older (80±6 vs 74±10, p=0.004), had lower forward stroke volume (72±19 vs 81±17 mL, p=0.04), higher E/e’ (13±5 vs 10±4, p=0.01), larger left atrial volume (51±19 vs 36±11mL/m2, p=0.002) and smaller AVA (0.85 ± 0.36 vs 1.04 ± 0.20 cm2, p=0.02). During a mean follow up time of 1.22±1.28 years, 43 (63%) patients underwent aortic valve surgery or TAVI, 5 cases of heart failure and 6 of death were identified. 10/11 CV events (91%) occurred in sMR patients (mean ERO 13.2±8.6 mm2). The HR for CV events for ERO 0.05 cm2 increase was 1.45 (95%CI 1.08-1.91), p=0.02; 1.47 (95%CI 1.07-1.98), p=0.02 after adjusting for AVA and 1.47 [95%CI 0.96-2.17], p=0.07 after adjustment for age.
CONCLUSIONS: In this pilot study, the presence of sMR in moderate-severe AS patients predicts CV events during the medical follow up. MR assessment through ERO may identify the patients who need to be followed up closely.
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