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Original research article
Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation
  1. Emilie Vitel1,
  2. Elena Galli1,2,3,
  3. Christophe Leclercq1,2,3,
  4. Maxime Fournet1,
  5. Christian Bosseau1,
  6. Hervé Corbineau2,3,4,5,
  7. Guillame Bouzille2,3,4,6,
  8. Erwan Donal1,2,3
  1. 1 Service de Cardiologie et Maladies Vasculaires, CHU Rennes, Rennes, France
  2. 2 Université Rennes-1, INSERM 1099, Rennes, France
  3. 3 LTSI, Université de Rennes 1, Rennes, France
  4. 4 Centre de Données Cliniques, CHU Rennes, Rennes, France
  5. 5 Department of Cardiovascular and Thoracic Surgery, CHU Rennes, Rennes, France
  6. 6 CIC et CIC--IT Inserm 1414, CHU Rennes, Rennes, France
  1. Correspondence to Dr Erwan Donal, Hôpital Pontchaillou-CHU Rennes, Service de Cardiologie, Rennes 35000, France; erwan.donal{at}


Objective To assess if the lack of development of right ventricular (RV) contractile reserve during exercise echocardiography (ex-echo) might be a predictor of postoperative major adverse cardiovascular events (MACEs) in patients with primary mitral regurgitation (pMR) undergoing early surgery.

Methods Comprehensive resting and ex-echo were performed in 142 asymptomatic patients (58±21 years, 68% men, New York Heart Association functional class ≤2) with isolated severe pMR and preserved left ventricular (LV) function (LV ejection >60%, LV end-systolic diameter <45 mm) undergoing mitral valve replacement (n=20) or repair. Postoperative MACEs were defined as occurrence of atrial fibrillation, stroke, cardiac-related hospitalisation or death. RV function was evaluated at rest in every patient during ex-echo by measuring their tricuspid annular plane systolic excursion (TAPSE) value.

Results After median follow-up of 30 months (IQR 16–60 months), MACEs occurred in 48 (34%) patients. Using Bayesian model averaging, among all the characteristics including the type of surgery, exercise TAPSE (ex-TAPSE) emerged as the most likely predictor of prognosis (HR 0.91, 95% CI 0.86 to 0.96). Other probable predictors were exercise fractional area change (HR 0.02, 95% CI 0.00 to 0.80), male gender (HR 0.40, 95% CI 0.21 to 0.75) and RV basal diameter (HR 1.06, 95% CI 0.98 to 1.14). In the receiver operating characteristic curve analysis, an ex-TAPSE value of <26 mm (sensitivity 73% (95% CI 61 to 84) and specificity of 86% (95% CI 77% to 93%)) defined RV dysfunction. Event-free survival at 5 years was significantly lower in the patient group that exhibited no development of RV contractile reserve during exercise: 43.9% (95% CI 31.3 to 61.4) vs 75.8% (95% CI 64.8 to 88.7).

Conclusion Lack of development of exercise-induced RV contractile reserve is a prognostic predictor in patients with severe pMR undergoing early mitral valve surgery.

  • mitral regurgitation
  • echocardiography
  • valve disease surgery

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  • EV and EG contributed equally.

  • Contributors All authors actively participated in the study. EV: conception and design of the study, interpretation of data, drafting of the manuscript. EG: conception and design of the work, acquisition and interpretation of data, drafting and critical revision of the manuscript. MF, CB: acquisition of data. CL: critical revision of the manuscript and final approval of the manuscript submitted. HC: acquisition of data, final approval of the manuscript submitted. GB: interpretation of data, drafting and critical revision of the manuscript. ED: conception and design of the study, interpretation of data, critical revision of the manuscript, final approval of the manuscript submitted.

  • Funding The study was supported by an institutional grant (CORECT 2014).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The protocol was approved by the local ethics committee (CPP Ouest V number: PIME 08/16-675).

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