Left ventricular mechanical load and contractile function in patients with chronic mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY

Left ventricular adaptation to chronic volume overload results in dramatic changes in ventricular geometry and hemodynamics. These changes are reflected in alterations in mechanical load and, eventually, contractile function.

METHODS

The study included 17 patients undergoing clinically driven invasive evaluation for mitral regurgitation (MR). Simultaneous catheter-tip manometry and M-mode echocardiography allowed for derivation of meridional and circumferential wall stress at end-diastole, end-systole, peak systole, and the average over the systolic ejection period. Assessment of contractile function was performed by analysis of: the overall group relationship between baseline end-systolic stress (ESS) and end-systolic dimension (ESD); subject-specific analysis of the relationship between ESS and ESD derived from pharmacologic load alteration; and subject- specific analysis of the relationship between left ventricular minor axis shortening and ESS. The acquired data were compared to data from 10 control subjects who were undergoing invasive evaluation and were free from cardiovascular disease.

RESULTS

Compared to controls, patients with chronic MR (mean regurgitant fraction 57%) were characterized by significantly increased angiographic end-diastolic and end-systolic volumes, lower cardiac indices, and similar left ventricular ejection fractions. Patients with chronic MR were also characterized by increased preload (end-diastolic stress) and afterload (mean systolic stress). ESS was not consistently increased in these patients, despite the increased chamber size. The severity of clinical symptoms was associated with the magnitude of alteration in afterload (mean systolic stress). Using different methodologies, a substantial prevalence of depressed contractile function was identified in those patients with preserved ejection fraction.

CONCLUSION

When compared to an age- and gender-matched controls, symptomatic patients with MR have similar left ventricular ejection performance in the setting of increased pre-load and after-load. Symptom severity was associated with increased afterload. The prevalence of contractile dysfunction in this setting was substantial.