Valvular heart disease
Risk, Determinants, and Outcome Implications of Progression of Mitral Regurgitation After Diagnosis of Mitral Valve Prolapse in a Single Community

https://doi.org/10.1016/j.amjcard.2007.10.029Get rights and content

To analyze the evolution of mitral regurgitation (MR) after the diagnosis of mitral valve prolapse in community patients, 285 residents of Olmsted County, Minnesota, diagnosed with mitral valve prolapse without severe MR were studied. MR grade was assessed at diagnosis and at follow-up 1,663 ± 1,079 days later using Doppler echocardiography. The progression of MR was defined as an increase of ≥1 MR grade. The patients’ mean age was 56 ± 22 years, 57% were women, and the mean ejection fraction was 60 ± 9%. Between diagnostic and follow-up echocardiography, 108 patients showed progression of MR, 39 of whom had progression ≥1 grade. The mean overall MR grade increased from 0.4 ± 0.7 to 0.9 ± 1.1 (p <0.01). The progression of MR was observed in all subsets, irrespective of age, gender, prolapse localization, leaflet thickening, and initial MR grade. However, multivariate analysis identified age (p <0.01) and initial MR grade (p = 0.01) as independent predictors of progression. In addition, MR progression was associated with greater left atrial enlargement (p <0.001), ventricular dilatation (p = 0.02 for increase in end-diastolic and end-systolic diameters), and a worse outcome (adjusted p = 0.001). In conclusion, in patients with mitral valve prolapse, MR progression was observed over time in all clinical and anatomic subsets and was associated with more severe ventricular and atrial remodeling and worse outcome.

Section snippets

Methods

Medical care in Olmsted County, Minnesota, is self-contained in the community, and the echocardiographic laboratory at our institution is the only provider of echocardiographic services in the county. Moreover, our institution is connected to all other potential medical care facilities in Olmsted County by the Rochester Epidemiology Project.5 It was therefore possible to identify all 803 residents of Olmsted County with a first diagnosis of MVP confirmed by echocardiography from January 1,

Results

From January 1, 1989, to December 31, 1998, 285 residents of Olmsted County diagnosed at our institution with MVP and with MR absent, mild, or moderate at diagnosis returned for repeat echocardiography during follow-up and were therefore included in this study. Indications for initial echocardiography were as follows: congestive heart failure or class III or IV symptoms in 23 patients (8%), ischemic neurologic events in 19 patients (7%), atrial fibrillation in 22 patients (8%), minor cardiac

Discussion

The present study included patients diagnosed in the community with a uniform cause of MR (i.e., MVP) and with various grades of MR, including none. These patients were followed up in the community, reflecting routine practice in mitral valve disease monitoring. Under these routine circumstances, our study showed that on average, the degree of MR increases with time and that MR progression is associated with progressive left ventricular and atrial remodeling and with poor outcomes. This

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    Nonetheless, our result cannot be interpreted as blood pressure control in AR is not important. Analogous to MR (16), baseline AR severity was powerful in predicting AR progression, supporting different intervals for follow-up according to baseline AR severity (i.e., moderate AR requires shorter follow-up) (3). In addition to guideline recommendations (i.e., that mild and moderate AR be followed every 3 to 5 years and 1 to 2 years, respectively), which did not address patients with mild-to-moderate AR, we propose that those with baseline trivial/mild, mild-to-moderate, and moderate AR be followed whenever symptoms change, or every 5, 3, and 1 years, respectively.

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