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Original research article
Net atrioventricular compliance is an independent predictor of cardiovascular death in mitral stenosis
  1. Maria Carmo Pereira Nunes1,2,
  2. Timothy C Tan2,
  3. Sammy Elmariah3,
  4. Lucas Lodi-Junqueira1,
  5. Bruno Ramos Nascimento1,
  6. Rodrigo do Lago3,
  7. Jose Luiz Padilha da Silva4,
  8. Rodrigo Citton Padilha Reis4,
  9. Xin Zeng2,
  10. Igor F Palacios3,
  11. Judy Hung2,
  12. Robert A Levine2
  1. 1Hospital das Clinicas, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
  2. 2Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Department of Statistics, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  1. Correspondence to Professor Maria Carmo Pereira Nunes, Department of Internal Medicine, School of Medicine of the Federal University of Minas Gerais.Av. Professor Alfredo Balena, 190, Santa Efigênia, Belo Horizonte 30130 100, Minas Gerais, Brazil; mcarmo{at}waymail.com.br

Abstract

Objectives Rheumatic mitral stenosis (MS) is a progressive disease, and risk of death may persist despite relief of the obstruction. Net atrioventricular compliance (Cn) modulates the overall haemodynamic burden of the MS and may be useful in predicting cardiovascular death after percutaneous mitral valvuloplasty (PMV).

Methods A total of 427 patients (mean age 50±16 years, 84% female) with severe MS undergoing PMV were enrolled. Doppler-derived Cn was estimated at baseline using a previously validated equation. The primary endpoint was late cardiovascular death, and the secondary endpoint was a composite of all-cause mortality, mitral valve (MV) replacement or repeat PMV over a median follow-up of 31 months (IQR: 7.8–49.2 months).

Results At baseline, 209 patients (49%) were in New York Heart Association (NYHA) functional class III or IV. During follow-up, 49 patients died (41 cardiovascular deaths), 50 underwent MV replacement and 12 required repeat PMV, with an overall incidence of cardiac mortality and adverse events of 4.1 deaths and 11.1 events per 100 patient-years, respectively. Low baseline Cn was a strong predictor of both cardiac death (adjusted HR 0.70, 95% CI 0.49 to 0.86) and composite endpoint (adjusted HR 0.81, 95% CI 0.67 to 0.91) after adjusting for clinical factors, baseline pulmonary artery pressure, tricuspid regurgitation severity, right ventricular function and immediate procedural haemodynamic data. The inclusion of Cn in a model with conventional parameters resulted in improvement in 5-year cardiovascular mortality risk prediction.

Conclusions Baseline Cn is a strong predictor of cardiovascular death in patients with MS undergoing PMV, independent of other prognostic markers of decreased survival in MS, including baseline patient characteristics and postprocedural data. Cn assessment therefore has potential value in evaluation of cardiovascular mortality risk in the setting of MS.

  • Rheumatic heart disease
  • net atrioventricular compliance
  • mitral stenosis
  • percutaneous mitral valvuloplasty
  • cardiovascular death
  • mortality

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Footnotes

  • Contributors All authors have read and approved the manuscript. None of them have declared conflict of interest. Each author has contributed significantly to the work.

  • Funding This study was partly supported by grants from Coordenação de Aperfeiçoamento de Pessoal deNível Superior (Brasília, Brazil); by National Institutes of Health/National Heart, Lung, and Blood Institute grants R01 HL092101 (JH), K24 HL67434 and R01 HL109506 (RAL); and by the Leducq Transatlantic Mitral Network (Paris, France; RAL).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The study protocol was approved by the institutional review board (IRB) of Massachusetts General Hospital (MGH), USA, and Federal University of Minas Gerais, Brazil.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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