Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: A multicenter analysis

Christophe Tribouilloy, Dan Rusinaru, Francesco Grigioni, Hector I Michelena, Jean Louis Vanoverschelde, Jean Francois Avierinos, Andrea Barbieri, Sorin V. Pislaru, Antonio Russo, Agnes Pasquet, Alexis Th́ron, Catherine Szymanski, Franck Ĺvy, Maurice E Sarano

Research output: Contribution to journalArticle

23 Citations (Scopus)

Abstract

Background-Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients. Methods and Results-We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66% [60%-71%]) enrolled in the Mitral Regurgitation International Database (MIDA) registry. With EF <60%, mortality after diagnosis increased precipitously under medical management (adjusted hazard ratio [HR], 1.59 [1.19-2.12]) and during the entire follow-up (adjusted HR, 1.51 [1.22-1.87]). Severe LV dysfunction, if defined by EF <30%, would affect a minuscule number of patients (0.3%). Conversely, EF <45% was more frequent (2.9%) and was associated with considerable mortality under medical management (adjusted HR, 2.43 [1.50-3.95]) and during the entire follow-up (adjusted HR, 2.46 [1.67-3.61]). The group with EF of 45% to 60% represented a large proportion of patients (23%), exhibited rarely overt symptoms, and had higher mortality compared with EF >60%. Above 60%, no EF threshold further determined survival. The benefit of surgery remained considerable in the groups with EF <45% (adjusted HR, 0.28 [0.17-0.56]) and with EF of 45% to 60% (adjusted HR, 0.34 [0.21-0.64]). Conclusions-EF is valuable in defining presence and severity of LV dysfunction in organic mitral regurgitation. Patients with EF <45% have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Although there is no survival gain with EF ranges >60%, with EF dropping <60%, mortality increases precipitously and prompt surgical referral is critical to outcome.

Original languageEnglish (US)
Pages (from-to)363-370
Number of pages8
JournalCirculation: Cardiovascular Imaging
Volume7
Issue number2
DOIs
StatePublished - 2014

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Mitral Valve Insufficiency
Left Ventricular Dysfunction
Mortality
Registries
Referral and Consultation
Databases
Survival

Keywords

  • Mitral Valve
  • Mitral Valve Insufficiency
  • Mortality
  • Surgery
  • Systole

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging

Cite this

Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets : A multicenter analysis. / Tribouilloy, Christophe; Rusinaru, Dan; Grigioni, Francesco; Michelena, Hector I; Vanoverschelde, Jean Louis; Avierinos, Jean Francois; Barbieri, Andrea; Pislaru, Sorin V.; Russo, Antonio; Pasquet, Agnes; Th́ron, Alexis; Szymanski, Catherine; Ĺvy, Franck; Sarano, Maurice E.

In: Circulation: Cardiovascular Imaging, Vol. 7, No. 2, 2014, p. 363-370.

Research output: Contribution to journalArticle

Tribouilloy, C, Rusinaru, D, Grigioni, F, Michelena, HI, Vanoverschelde, JL, Avierinos, JF, Barbieri, A, Pislaru, SV, Russo, A, Pasquet, A, Th́ron, A, Szymanski, C, Ĺvy, F & Sarano, ME 2014, 'Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: A multicenter analysis', Circulation: Cardiovascular Imaging, vol. 7, no. 2, pp. 363-370. https://doi.org/10.1161/CIRCIMAGING.113.001251
Tribouilloy, Christophe ; Rusinaru, Dan ; Grigioni, Francesco ; Michelena, Hector I ; Vanoverschelde, Jean Louis ; Avierinos, Jean Francois ; Barbieri, Andrea ; Pislaru, Sorin V. ; Russo, Antonio ; Pasquet, Agnes ; Th́ron, Alexis ; Szymanski, Catherine ; Ĺvy, Franck ; Sarano, Maurice E. / Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets : A multicenter analysis. In: Circulation: Cardiovascular Imaging. 2014 ; Vol. 7, No. 2. pp. 363-370.
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abstract = "Background-Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients. Methods and Results-We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66{\%} [60{\%}-71{\%}]) enrolled in the Mitral Regurgitation International Database (MIDA) registry. With EF <60{\%}, mortality after diagnosis increased precipitously under medical management (adjusted hazard ratio [HR], 1.59 [1.19-2.12]) and during the entire follow-up (adjusted HR, 1.51 [1.22-1.87]). Severe LV dysfunction, if defined by EF <30{\%}, would affect a minuscule number of patients (0.3{\%}). Conversely, EF <45{\%} was more frequent (2.9{\%}) and was associated with considerable mortality under medical management (adjusted HR, 2.43 [1.50-3.95]) and during the entire follow-up (adjusted HR, 2.46 [1.67-3.61]). The group with EF of 45{\%} to 60{\%} represented a large proportion of patients (23{\%}), exhibited rarely overt symptoms, and had higher mortality compared with EF >60{\%}. Above 60{\%}, no EF threshold further determined survival. The benefit of surgery remained considerable in the groups with EF <45{\%} (adjusted HR, 0.28 [0.17-0.56]) and with EF of 45{\%} to 60{\%} (adjusted HR, 0.34 [0.21-0.64]). Conclusions-EF is valuable in defining presence and severity of LV dysfunction in organic mitral regurgitation. Patients with EF <45{\%} have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Although there is no survival gain with EF ranges >60{\%}, with EF dropping <60{\%}, mortality increases precipitously and prompt surgical referral is critical to outcome.",
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T1 - Long-term mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets

T2 - A multicenter analysis

AU - Tribouilloy, Christophe

AU - Rusinaru, Dan

AU - Grigioni, Francesco

AU - Michelena, Hector I

AU - Vanoverschelde, Jean Louis

AU - Avierinos, Jean Francois

AU - Barbieri, Andrea

AU - Pislaru, Sorin V.

AU - Russo, Antonio

AU - Pasquet, Agnes

AU - Th́ron, Alexis

AU - Szymanski, Catherine

AU - Ĺvy, Franck

AU - Sarano, Maurice E

PY - 2014

Y1 - 2014

N2 - Background-Ejection fraction (EF) as a marker of left ventricular (LV) dysfunction and the appropriate thresholds for diagnosing severe or mild/moderate LV dysfunction in mitral regurgitation are doubted and poorly followed in clinical practice. We aimed at assessing the role of EF in a large registry of organic mitral regurgitation to objectively establish thresholds for various degrees of LV dysfunction and to analyze whether mitral surgery remains beneficial in those subsets of patients. Methods and Results-We investigated the relation between EF and mortality in 1875 patients with mitral regurgitation due to flail leaflets in sinus rhythm (65±13 years; median EF, 66% [60%-71%]) enrolled in the Mitral Regurgitation International Database (MIDA) registry. With EF <60%, mortality after diagnosis increased precipitously under medical management (adjusted hazard ratio [HR], 1.59 [1.19-2.12]) and during the entire follow-up (adjusted HR, 1.51 [1.22-1.87]). Severe LV dysfunction, if defined by EF <30%, would affect a minuscule number of patients (0.3%). Conversely, EF <45% was more frequent (2.9%) and was associated with considerable mortality under medical management (adjusted HR, 2.43 [1.50-3.95]) and during the entire follow-up (adjusted HR, 2.46 [1.67-3.61]). The group with EF of 45% to 60% represented a large proportion of patients (23%), exhibited rarely overt symptoms, and had higher mortality compared with EF >60%. Above 60%, no EF threshold further determined survival. The benefit of surgery remained considerable in the groups with EF <45% (adjusted HR, 0.28 [0.17-0.56]) and with EF of 45% to 60% (adjusted HR, 0.34 [0.21-0.64]). Conclusions-EF is valuable in defining presence and severity of LV dysfunction in organic mitral regurgitation. Patients with EF <45% have severe LV dysfunction, catastrophic outcome under medical management, and should not be denied surgery. Although there is no survival gain with EF ranges >60%, with EF dropping <60%, mortality increases precipitously and prompt surgical referral is critical to outcome.

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KW - Mitral Valve

KW - Mitral Valve Insufficiency

KW - Mortality

KW - Surgery

KW - Systole

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