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• W3210658391 abstract "Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR. Patients with secondary mitral regurgitation (SMR) often have extramitral valve cardiac involvement, which can influence the prognosis. SMR can be defined according to groups of extramitral valve cardiac involvement. The prognostic implications of such groups in patients with moderate and severe SMR (significant SMR) are unknown. A total of 325 patients with significant SMR were classified according to the extent of cardiac involvement on echocardiography: left ventricular involvement (group 1), left atrial involvement (group 2), tricuspid valve and pulmonary artery vasculature involvement (group 3), or right ventricular involvement (group 4). The primary end point was all-cause mortality. The prevalence of each cardiac involvement group was 17% in group 1, 12% in group 2, 23% in group 3%, and 48% in group 4. Group 3 and group 4 were independently associated with all-cause mortality (hazard ratio 1.794, 95% confidence interval 1.067 to 3.015, p = 0.027 and hazard ratio 1.857, 95% confidence interval 1.145 to 3.012, p = 0.012, respectively). In conclusion, progressive extramitral valve cardiac involvement (group 3 and group 4) was independently associated with all-cause mortality in patients with significant SMR. Guideline-directed medical therapy for heart failure (including cardiac resynchronization therapy [CRT]) has been demonstrated to reverse left ventricular (LV) remodeling and reduce secondary mitral regurgitation (SMR) in selected patients.1Nasser R Van Assche L Vorlat A Vermeulen T Van Craenenbroeck E Conraads V Van der Meiren V Shivalkar B Van Herck P Claeys MJ. Evolution of functional mitral regurgitation and prognosis in medically managed heart failure patients with reduced ejection fraction.JACC Heart Fail. 2017; 5: 652-659Crossref PubMed Scopus (72) Google Scholar,2St John Sutton MG Plappert T Abraham WT Smith AL DeLurgio DB Leon AR Loh E Kocovic DZ Fisher WG Ellestad M Messenger J Kruger K Hilpisch KE Hill MR Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study Group. Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure.Circulation. 2003; 107: 1985-1990Crossref PubMed Scopus (964) Google Scholar However, patients who remain with moderate-to-severe or severe SMR despite guideline-directed medical therapy exhibit high morbidity and mortality.3Agricola E Ielasi A Oppizzi M Faggiano P Ferri L Calabrese A Vizzardi E Alfieri O Margonato A. Long-term prognosis of medically treated patients with functional mitral regurgitation and left ventricular dysfunction.Eur J Heart Fail. 2009; 11: 581-587Crossref PubMed Scopus (122) Google Scholar The high operative risk and relatively high SMR recurrence rate may explain the low referral rate for mitral valve intervention.4Goldstein D Moskowitz AJ Gelijns AC Ailawadi G Parides MK Perrault LP Hung JW Voisine P Dagenais F Gillinov AM Thourani V Argenziano M Gammie JS Mack M Demers P Atluri P Rose EA O'Sullivan K Williams DL Bagiella E Michler RE Weisel RD Miller MA Geller NL Taddei-Peters WC Smith PK Moquete E Overbey JR Kron IL O'Gara PT Acker MA CTSNTwo-year outcomes of surgical treatment of severe ischemic mitral regurgitation.N Engl J Med. 2016; 374: 344-353Crossref PubMed Scopus (543) Google Scholar, 5Lorusso R Gelsomino S Vizzardi E D'Aloia A De Cicco G Lucà F Parise O Gensini GF Stefàno P Livi U Vendramin I Pacini D Di Bartolomeo R Miceli A Varone E Glauber M Parolari A Giuseppe Arlati F Alamanni F Serraino F Renzulli A Messina A Troise G Mariscalco G Cottini M Beghi C Nicolini F Gherli T Borghetti V Pardini A Caimmi PP Micalizzi E Fino C Ferrazzi P Di Mauro M Calafiore AM ISTIMIR InvestigatorsMitral valve repair or replacement for ischemic mitral regurgitation? The Italian study on the treatment of ischemic mitral regurgitation (ISTIMIR).J Thorac Cardiovasc Surg. 2013; 145: 128-138Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 6Petrus AHJ Dekkers OM Tops LF Timmer E Klautz RJM Braun J. Impact of recurrent mitral regurgitation after mitral valve repair for functional mitral regurgitation: long-term analysis of competing outcomes.Eur Heart J. 2019; 40: 2206-2214Crossref PubMed Scopus (42) Google Scholar More recently, transcatheter mitral valve repair with MitraClip (Abbott, Abbott Park, Illinois) was demonstrated to improve the prognosis of selected patients with heart failure and SMR with symptoms refractory to medical therapy.7Stone GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google Scholar The echocardiographic criteria that indicate the need for mitral valve intervention comprise measures of SMR severity, LV ejection fraction (LVEF), and LV volumes.7Stone GW Lindenfeld J Abraham WT Kar S Lim DS Mishell JM Whisenant B Grayburn PA Rinaldi M Kapadia SR Rajagopal V Sarembock IJ Brieke A Marx SO Cohen DJ Weissman NJ Mack MJ COAPT InvestigatorsTranscatheter mitral-valve repair in patients with heart failure.N Engl J Med. 2018; 379: 2307-2318Crossref PubMed Scopus (1458) Google Scholar, 8Baumgartner H Falk V Bax JJ De Bonis M Hamm C Holm PJ Iung B Lancellotti P Lansac E Rodriguez Muñoz D Rosenhek R Sjögren J Tornos Mas P Vahanian A Walther T Wendler O Windecker S Zamorano JL ESC Scientific Document Group2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Crossref PubMed Scopus (2) Google Scholar, 9Nishimura RA Otto CM Bonow RO Carabello BA 3rd Erwin JP Fleisher LA Jneid H Mack MJ McLeod CJ O'Gara PT Rigolin VH Sundt 3rd, TM Thompson A 2017 aha/acc focused update of the 2014 aha/acc guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol. 2017; 70: 252-289Crossref PubMed Scopus (1781) Google Scholar However, the spectrum of cardiac abnormalities that accompany SMR and that influence patient outcomes is broader. Cardiac classification algorithms have been applied to severe aortic stenosis and have shown that extra-aortic valve, cardiac involvement provides incremental prognostic value over measures of aortic stenosis severity.10Généreux P Pibarot P Redfors B Mack MJ Makkar RR Jaber WA Svensson LG Kapadia S Tuzcu EM Thourani VH Babaliaros V Herrmann HC Szeto WY Cohen DJ Lindman BR McAndrew T Alu MC Douglas PS Hahn RT Kodali SK Smith CR Miller DC Webb JG Leon MB. Staging classification of aortic stenosis based on the extent of cardiac damage.Eur Heart J. 2017; 38: 3351-3358Crossref PubMed Scopus (217) Google Scholar Accordingly, the present study proposes an algorithm to divide patients with SMR into groups based on their extramitral valve, cardiac involvement and evaluated its prognostic implications. Patients with moderate and severe SMR (significant SMR) and reduced LVEF <50% were identified between 1999 and 2018 from ongoing registries of patients with SMR at the Leiden University Medical Center (The Netherlands) and are included in this analysis. Patients were classified into 4 groups of cardiac involvement, based on the presence of extramitral valvular cardiac involvement derived from the first echocardiogram performed with patients in a hemodynamic stable condition showing significant SMR (Figure 1): group 1: LV involvement (LV end-diastolic diameter ≥57 mm and/or LVEF <50%); group 2: left atrial (LA) involvement (LA volume index >34 ml/m2 and/or history of atrial fibrillation); group 3: tricuspid valve or pulmonary artery vasculature involvement (systolic pulmonary artery pressure [SPAP] ≥40 mm Hg and/or significant tricuspid regurgitation [TR]); group 4: right ventricular (RV) involvement (tricuspid annular plane systolic excursion [TAPSE] ≤17 mm). Importantly, patients were classified according to the highest cardiac involvement group; thus, for example, if patients had LVEF <50% and TAPSE ≤17 mm, they were included in group 4. Patients with previous mitral valve intervention (surgical mitral valve repair, mitral valve replacement, or transcatheter edge-to-edge mitral valve repair) or incomplete echocardiographic data to determine the extramitral valvular cardiac involvement were excluded. Clinical and demographic data were collected using the departmental patient information system. For retrospective analysis of clinically acquired data which were anonymously handled, the institutional review board waived the need for patient written informed consent. Transthoracic echocardiography was performed with the patients at rest, lying in the left lateral decubitus position, using commercially available ultrasound systems (GE Vingmed Ultrasound, General Electric, Milwaukee, Wisconsin) equipped with 3.5 MHz or M5S transducers. Two-dimensional and Doppler data were acquired from parasternal, apical, and subcostal views. LV end-diastolic diameter was measured on the parasternal long-axis view.11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (4143) Google Scholar The apical 2- and 4-chamber views were used to measure the LV end-diastolic and end-systolic volumes, and LVEF was calculated according to Simpson's biplane method.11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (4143) Google Scholar LA volumes were measured at the end of ventricular systole on the 2- and 4-chamber apical views, using the biplane method of disks, and indexed for body surface area (LA volume index).11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (4143) Google Scholar Stroke volume was calculated with the following equation: Stroke volume = LV outflow tract velocity time integral × cross-sectional area of the LV outflow tract.12Zoghbi WA Adams D Bonow RO Enriquez-Sarano M Foster E Grayburn PA Hahn RT Han Y Hung J Lang RM Little SH Shah DJ Shernan S Thavendiranathan P Thomas JD Weissman NJ. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the society for cardiovascular magnetic resonance.J Am Soc Echocardiogr. 2017; 30: 303-371Abstract Full Text Full Text PDF PubMed Scopus (1523) Google Scholar The severity of mitral regurgitation was assessed according to current recommendations, using qualitative, semiquantitative, and quantitative data. If measurable, quantitative measurements were conducted according to the proximal isovelocity surface area method, for which the effective regurgitant orifice area was measured and regurgitant volume was calculated by multiplying effective regurgitant orifice area by the mitral valve velocity time integral.12Zoghbi WA Adams D Bonow RO Enriquez-Sarano M Foster E Grayburn PA Hahn RT Han Y Hung J Lang RM Little SH Shah DJ Shernan S Thavendiranathan P Thomas JD Weissman NJ. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the society for cardiovascular magnetic resonance.J Am Soc Echocardiogr. 2017; 30: 303-371Abstract Full Text Full Text PDF PubMed Scopus (1523) Google Scholar,13Lancellotti P Tribouilloy C Hagendorff A Popescu BA Edvardsen T Pierard LA Badano L Zamorano JL Scientific Document Committee of the European Association of CardiovascularRecommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2013; 14: 611-644Crossref PubMed Scopus (1063) Google Scholar The severity of TR was semiquantitatively assessed using vena contracta width: mild <0.3 cm, moderate 0.3 to 0.69 cm, and severe ≥0.7 cm.12Zoghbi WA Adams D Bonow RO Enriquez-Sarano M Foster E Grayburn PA Hahn RT Han Y Hung J Lang RM Little SH Shah DJ Shernan S Thavendiranathan P Thomas JD Weissman NJ. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the society for cardiovascular magnetic resonance.J Am Soc Echocardiogr. 2017; 30: 303-371Abstract Full Text Full Text PDF PubMed Scopus (1523) Google Scholar,13Lancellotti P Tribouilloy C Hagendorff A Popescu BA Edvardsen T Pierard LA Badano L Zamorano JL Scientific Document Committee of the European Association of CardiovascularRecommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2013; 14: 611-644Crossref PubMed Scopus (1063) Google Scholar Significant TR was defined as moderate or severe TR. RV systolic function was assessed using the TAPSE measured on the focused 4-chamber apical view and M-mode.11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (4143) Google Scholar,14Rudski LG Lai WW Afilalo J Hua L Handschumacher MD Chandrasekaran K Solomon SD Louie EK Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.J Am Soc Echocardiogr. 2010; 23: 685-788Abstract Full Text Full Text PDF PubMed Scopus (4759) Google Scholar To estimate the SPAP the RV pressure was calculated from the peak velocity of the TR jet, according to the simplified Bernoulli's equation, to which the right atrial pressure was identified by the inspiratory collapse and diameter of the inferior vena cava were added.11Lang RM Badano LP Mor-Avi V Afilalo J Armstrong A Ernande L Flachskampf FA Foster E Goldstein SA Kuznetsova T Lancellotti P Muraru D Picard MH Rietzschel ER Rudski L Spencer KT Tsang W Voigt JU. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270Crossref PubMed Scopus (4143) Google Scholar,14Rudski LG Lai WW Afilalo J Hua L Handschumacher MD Chandrasekaran K Solomon SD Louie EK Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.J Am Soc Echocardiogr. 2010; 23: 685-788Abstract Full Text Full Text PDF PubMed Scopus (4759) Google Scholar Patients were followed up for the occurrence of mitral valve intervention (i.e., surgical mitral valve repair, mitral valve replacement, and percutaneous edge-to-edge mitral valve repair) and all-cause mortality. The primary outcome was all-cause mortality. Mortality data were collected from the departmental patient information system, which is linked to the governmental death registry database. In addition, to evaluate the heart failure treatment in this population, the occurrence of CRT was investigated. Continuous data are presented as mean ± SD when normally distributed or as median and interquartile range when non-normally distributed. Categorical data are presented as frequencies and percentages. Comparison of continuous data, when normally distributed, was performed using the one-way analysis of variance analysis with Bonferroni's post hoc analysis or, when non-normally distributed, with the Kruskal-Wallis test. Categorical data were compared using the chi-square test. Kaplan-Meier analysis was used to estimate the event-free survival rates of patients in the various groups during follow-up. The event-free survival rates were compared using the log-rank test. Univariable Cox proportional hazards analysis was performed to evaluate the association between the extramitral valvular cardiac involvement groups and other clinical and echocardiographic variables with all-cause mortality. Mitral valve intervention was also included as a time-dependent variable in this analysis. The hazard ratio and 95% confidence interval were reported. In the univariable analysis, clinically relevant variables were selected and included in the multivariable Cox proportional hazards model. A two-sided p <0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 25.0. (Armonk, New York: IBM Corp.) A total of 325 patients (mean age 69 ± 10 years, 66% male) with severely reduced LVEF (mean 29 ± 9%) were included. The distribution of patients across the different groups of cardiac involvement is presented in Figure 2. The clinical and echocardiographic characteristics of the overall population and for each cardiac involvement group are listed in Tables 1 and 2, respectively. Patients in group 4 (RV involvement) were older and had worse kidney function compared with group 1 (LV involvement). During a median follow-up of 67 months (interquartile range: 27 to 121 months), 192 patients died (59%), 148 patients (46%) underwent mitral valve intervention and 258 patients (79%) received CRT (Table 3). The Kaplan-Meier analysis for all-cause mortality in the total population is shown in Figure 3. Patients in group 1 had better survival as compared with the patients in groups 3 and 4. The 1- and 8-year mortality rates for patients in group 1 were 6% and 33% respectively, which is lower than the mortality rates of patients in groups 3 and 4, which were 12% and 17% at 1-year and 53%, and 57% at 8 years of follow-up, respectively.Table 1Clinical characteristics according to cardiac involvementVariableTotal population (n=325)Group 1 LV involvement (n=54)Group 2 LA involvement (n=40)Group 3 TV or pulmonary artery vasculature involvement (n=76)Group 4 RV involvement (n=155)p-valueMale213 (66%)32 (59%)25 (63%)48 (63%)108 (70%)0.480Age (years)69 ± 1062 ± 1267 ± 1266 ± 1068 ± 9*p<0.05 versus stage 1. ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; COPD = chronic obstructive pulmonary disease; CRT = cardiac resynchronization therapy; LA = left atrial; LV = left ventricular; NYHA = New York Heart Association; RV = right ventricular; TV = tricuspid valve.0.001Body surface area (m2)1.9 ± 0.211.9 ± 0.211.9 ± 0.231.9 ± 0.211.9 ± 0.200.987Creatinine (µmol/L)101 (81-136)90 (75-117)103 (75-132)98 (87-133)109 (85-153)*p<0.05 versus stage 1. ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; COPD = chronic obstructive pulmonary disease; CRT = cardiac resynchronization therapy; LA = left atrial; LV = left ventricular; NYHA = New York Heart Association; RV = right ventricular; TV = tricuspid valve.0.009NYHA ≥ II306 (94%)51 (94%)38 (95%)71 (93%)146 (94%)0.987Atrial fibrillation172 (53%)0 (0%)23 (58%)40 (53%)109 (70%)<0.001CRT33 (10%)3 (6%)5 (13%)5 (7%)20 (13%)0.279Diabetes mellitus69 (21%)9 (17%)7 (18%)15 (20%)38 (25%)0.550Hypertension132 (41%)22 (41%)18 (45%)28 (37%)64 (41%)0.850COPD38 (12%)4 (7%)3 (8%)10 (13%)21 (14%)0.509Beta-blocker236 (73%)41 (76%)28 (70%)54 (71%)113 (73%)0.911ACE or ARB263 (81%)46 (85%)34 (85%)64 (84%)119 (77%)0.344Diuretics278 (86%)42 (78%)29 (73%)66 (87%)141 (91%)0.008Values are mean ± SD, median [IQR], or n (%). p<0.05 versus stage 1.ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; COPD = chronic obstructive pulmonary disease; CRT = cardiac resynchronization therapy; LA = left atrial; LV = left ventricular; NYHA = New York Heart Association; RV = right ventricular; TV = tricuspid valve. Open table in a new tab Table 2Echocardiographic characteristics according to cardiac involvementVariableTotal population (n=325)Group 1 LV involvement (n=54)Group 2 LA involvement (n=40)Group 3 TV or pulmonary artery vasculature involvement (n=76)Group 4 RV involvement (n=155)p-valueLV end-diastolic diameter (mm)67 ± 1067 ± 970 ± 1167 ± 1165 ± 90.073LV end-diastolic volume (ml)196 (144-250)209 (172-255)200 (129-268)193 (144-248)185 (139-240)0.304LV end-systolic volume (ml)142 (97-184)155 (110-188)135 (88-186)138 (97-181)136 (93-186)0.468Stroke volume (ml)43 ± 1346 ± 1247 ± 1243 ± 1140 ± 14*p<0.05 versus stage 1.,†p<0.05 versus stage 2.0.005LV ejection fraction (%)29 ± 928 ± 930 ± 930 ± 928 ± 90.452Left atrial volume index (ml/m2)38 (29-49)25 (19-30)40 (34-52)*p<0.05 versus stage 1.38 (35-49)*p<0.05 versus stage 1.44 (36-56)*p<0.05 versus stage 1.<0.001SPAP (mmHg)43 ± 1328 ± 732 ± 649 ± 12*p<0.05 versus stage 1.,†p<0.05 versus stage 2.49 ± 12*p<0.05 versus stage 1.,†p<0.05 versus stage 2.<0.001TAPSE (mm)18 (13-20)20 (19-22)19 (18-21)20 (18-23)13 (11-15)*p<0.05 versus stage 1.,†p<0.05 versus stage 2.‡p<0.05 versus stage 3. EROA = effective regurgitant orifice area; LA = left atrial; LV = left ventricular; RV = right ventricular; SMR = secondary mitral regurgitation; SPAP = systolic pulmonary artery pressure; TAPSE = tricuspid annular plane systolic excursion; TV = tricuspid valve.<0.001EROA (mm2)20 (14-29)16 (12-20)19 (11-24)20 (15-30)*p<0.05 versus stage 1.20 (15-30)*p<0.05 versus stage 1.0.006Regurgitant volume (ml)31 ± 1528 ± 1531 ± 1333 ± 1631 ± 150.405Mitral regurgitation0.002Moderate52 (16%)15 (28%)6 (15%)9 (12%)22 (14%)Moderate-severe129 (40%)28 (52%)20 (50%)27 (36%)54 (35%)Severe144 (44%)11 (20%)14 (35%)40 (53%)79 (51%)Tricuspid regurgitation<0.001Moderate74 (23%)0 (0%)0 (0%)18 (25%)56 (37%)Severe23 (7%)0 (0%)0 (0%)6 (8%)17 (11%)Values are mean ± SD, median [IQR], or n (%). Missing: EROA 91/325; left atrial volume index 2/325; regurgitant volume 92/325; SPAP 5/325; stroke volume 34/325; tricuspid regurgitation 4/325. p<0.05 versus stage 1.† p<0.05 versus stage 2.‡ p<0.05 versus stage 3.EROA = effective regurgitant orifice area; LA = left atrial; LV = left ventricular; RV = right ventricular; SMR = secondary mitral regurgitation; SPAP = systolic pulmonary artery pressure; TAPSE = tricuspid annular plane systolic excursion; TV = tricuspid valve. Open table in a new tab Table 3Clinical outcomes during follow-upVariableTotal population (n=325)Group 1 LV involvement (n=54)Group 2 LA involvement (n=40)Group 3 TV or pulmonary artery vasculature involvement (n=76)Group 4 RV involvement (n=155)p-valueCRT at baseline + follow-up258 (79%)47 (87%)29 (73%)60 (79%)122 (79%)0.370MV intervention at follow-up0.168Transcatheter edge-to-edge repair51 (16%)3 (6%)7 (18%)9 (12%)32 (21%)MV repair95 (29%)13 (24%)13 (33%)27 (36%)42 (27%)MV replacement2 (1%)--1 (1%)1 (1%)Concomitant TVP71 (22%)8 (15%)7 (18%)19 (25%)37 (24%)0.420Concomitant AVR2 (1%)1 (2%)-1 (1%)-0.367Concomitant CABG29 (9%)5 (9%)2 (5%)10 (13%)12 (8%)0.439Values are n (%). CRT at baseline is included in this follow-up table.AVR = aortic valve replacement; CABG = coronary artery bypass graft; CRT = cardiac resynchronization therapy; LA = left atrial; LV = left ventricular; MV = mitral valve; RV = right ventricular; TV = tricuspid; TVP = tricuspid valvuloplasty. Open table in a new tab Figure 3Kaplan-Meier curve analysis for all-cause mortality for the overall population according to the groups of cardiac involvement. Group 1 = Left ventricular involvement; Group 2 = Left atrial involvement; Group 3 = Tricuspid valve or pulmonary artery vasculature involvement; Group 4 = Right ventricular involvement.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Values are mean ± SD, median [IQR], or n (%). Values are mean ± SD, median [IQR], or n (%). Missing: EROA 91/325; left atrial volume index 2/325; regurgitant volume 92/325; SPAP 5/325; stroke volume 34/325; tricuspid regurgitation 4/325. Values are n (%). CRT at baseline is included in this follow-up table. AVR = aortic valve replacement; CABG = coronary artery bypass graft; CRT = cardiac resynchronization therapy; LA = left atrial; LV = left ventricular; MV = mitral valve; RV = right ventricular; TV = tricuspid; TVP = tricuspid valvuloplasty. The univariable and multivariable Cox regression analysis evaluating the association between the groups of extramitral valvular cardiac involvement and all-cause mortality in the total population are listed in Table 4. In the univariable analysis, group 3 and group 4 were significantly associated with all-cause mortality. After correcting for age, male gender, kidney function, and chronic obstructive pulmonary disease, groups 3 and 4 remained independently associated with worse survival.Table 4Univariable and multivariable Cox proportional hazard analysis in the total populationUnivariable AnalysisMultivariable AnalysisHR (95% CI)p-valueHR (95% CI)p-valueAge (years)1.032 (1.017-1.048)<0.0011.025 (1.009-1.041)0.002Men1.622 (1.184-2.224)0.0031.220 (0.878-1.694)0.236Creatinine (µmol/L)1.007 (1.005-1.009)<0.0011.005 (1.003-1.008)<0.001Atrial fibrillation1.268 (0.952-1.687)0.104COPD2.005 (1.367-2.939)<0.0011.434 (0.968-2.123)0.072MV intervention at follow-up1.166 (0.875-1.555)0.295LV ejection fraction (%)0.981 (0.965-0.997)0.018LA volume index (ml/m2)1.011 (1.004-1.017)0.002SPAP (mmHg)1.026 (1.015-1.036)<0.001Significant TR1.412 (1.042-1.913)0.026TAPSE (mm)0.957 (0.929-0.987)0.005SMR moderate (reference)<0.001 SMR moderate-severe2.951 (1.766-4.933) SMR severe3.516 (2.111-5.857)Group 1 (reference) Group 21.386 (0.751-2.560)0.2961.114 (0.600-2.070)0.732 Group 32.165 (1.294-3.622)0.0031.794 (1.067-3.015)0.027 Group 42.562 (1.598-4.107)<0.0011.857 (1.145-3.012)0.012COPD = chronic obstructive pulmonary disease; LA = left atrial; LV = left ventricular; MV = mitral valve; SMR = secondary mitral regurgitation; SPAP = systolic pulmonary artery pressure; TAPSE = tricuspid annular plane systolic excursion; TR = tricuspid regurgitation. Group 1 = LV involvement; Group 2 = LA involvement; Group 3 = Tricuspid valve or pulmonary artery vasculature involvement; Group 4 = Right ventricular involvement. Open table in a new tab COPD = chronic obstructive pulmonary disease; LA = left atrial; LV = left ventricular; MV = mitral valve; SMR = secondary mitral regurgitation; SPAP = systolic pulmonary artery pressure; TAPSE = tricuspid annular plane systolic excursion; TR = tricuspid regurgitation. Group 1 = LV involvement; Group 2 = LA involvement; Group 3 = Tricuspid valve or pulmonary artery vasculature involvement; Group 4 = Right ventricular involvement. The univariable and multivariable Cox regression analysis evaluating the association between the groups of extramitral valvular cardiac involvement and all-cause mortality in the total population, while adding mitral valve intervention a" @default.
• W3210658391 created "2021-11-08" @default.
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• W3210658391 date "2022-01-01" @default.
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• W3210658391 title "Extramitral Valvular Cardiac Involvement in Patients With Significant Secondary Mitral Regurgitation" @default.
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