CARDIOVASCULAR MEDICINE

Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation

R Lee¹, B Haluska¹, D Y Leung², C Case¹, J Mundy¹, T H Marwick¹

¹ University of Queensland, Brisbane, Australia
² University of New South Wales, Sydney, Australia

Correspondence to:
Correspondence to:
Professor Thomas H Marwick
University of Queensland Department of Medicine, Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia; tmarwick{at}soms.uq.edu.au

Objective: To evaluate contractile reserve (CR) determined by exercise echocardiography in predicting clinical outcome and left ventricular (LV) function in asymptomatic severe mitral regurgitation (MR).

Design: Cohort study.

Setting: Regional cardiac centre.

Patients and outcome measures: LV volumes and ejection fraction (EF) were measured at rest and after stress in 71 patients with isolated MR. During follow up (mean (SD) 3 (1) years), EF and functional capacity were serially assessed and cardiac events (cardiac death, heart failure, and new atrial fibrillation) were documented.

Results: CR was present in 45 patients (CR+) and absent in 26 patients (CR–). Age, resting LV dimensions, EF, and MR severity were similar in both groups. Mitral surgery was performed in 19 of 45 (42%) CR+ patients and 22 of 26 (85%) CR– patients. In patients undergoing surgery, CR was an independent predictor of follow up EF (p = 0.006) and postoperative LV dysfunction (EF < 50%) persisted in five patients, all in the CR– group. Event-free survival was lower in surgically treated patients without CR (p = 0.03). In medically treated patients, follow up EF was preserved in those with intact CR but progressively deteriorated in patients without CR, in whom functional capacity also deteriorated.

Conclusions: Evaluation of CR by exercise echocardiography may be useful for risk stratification and may help to optimise the timing of surgery in asymptomatic severe MR.

Abbreviations: CR, contractile reserve; EF, ejection fraction; LV, left ventricular; METS, metabolic equivalents; MR, mitral regurgitation; NYHA, New York Heart Association

Keywords: contractile reserve; mitral regurgitation; exercise echocardiography; left ventricular function; mitral valve surgery

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