Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
J Am Coll Cardiol. 2020 Jul 21;76(3):233-246. doi: 10.1016/j.jacc.2020.05.051.
Etiology, mechanisms, and survival of mitral regurgitation (MR) plus hemodynamically-significant chronic aortic regurgitation (AR) are mostly unknown.
The purpose of this study was to investigate the prevalence, mechanisms, etiologies, and survival impact of coexistent ≥ moderate MR in AR patients.
Consecutive patients with ≥ moderate-severe AR were retrospectively identified between 2004 and 2019.
Of 1,239 eligible patients (61 ± 18 years, 80% men), 1,072 (86%) had pure AR, and 167 (14%) had AR + MR (9% functional mitral regurgitation [FMR] [84% nonischemic] and 5% organic mitral regurgitation [OMR] [62% degenerative]). At baseline transthoracic echocardiogram, pure AR versus AR + OMR versus AR + FMR exhibited differences in age (59 ± 18, 62 ± 16, and 73 ± 14 years, respectively), female sex (18%, 27%, and 39%, respectively), symptoms (36%, 41%, and 64%, respectively), atrial fibrillation (5%, 17%, and 36%, respectively), left ventricular (LV) ejection fraction (59%, 58%, and 46%, respectively), LV end-systolic dimension and volume index, ≥ moderate tricuspid regurgitation (TR) (7%, 35%, and 53%, respectively), and right ventricular systolic pressure (32 ± 11, 45 ± 15, and 50 ± 14 mm Hg, respectively), all p < 0.0001. After a median follow-up of 5.2 years (interquartile range: 2.2 to 10.0 years) and adjusting for demographics, New York Heart Association functional class, aortic valve surgery, LV ejection fraction, LV end-systolic dimension and volume index, presence of FMR was independently associated with all-cause mortality (p ≤ 0.004). Compared with pure AR, AR + MR + TR exhibited the highest adjusted risk of death (2.4-fold; p < 0.0001). When compared with expected population survival, excess mortality risks of pure AR, AR + OMR, and AR + FMR were 1.25-fold, 1.76-fold, and 2.34-fold, respectively (all p ≤ 0.02).
In hemodynamically significant AR, coexistent MR is not uncommon (approximately 14%) and mostly comprises FMR and less commonly OMR. As compared with pure AR, AR + MR + TR exhibit the largest mortality risk. Both AR + OMR and AR + FMR carry a survival penalty compared with the general population, but AR + FMR is associated with the largest excess mortality and represents an advanced stage within the AR clinical spectrum.
二尖瓣反流（MR）合并血流动力学显著慢性主动脉瓣反流（AR）的病因、机制和生存情况大多未知。
本研究旨在探讨 AR 患者并存≥中度 MR 的患病率、机制、病因和对生存的影响。
回顾性分析 2004 年至 2019 年间连续就诊的≥重度 AR 患者。
在 1239 名符合条件的患者（61±18 岁，80%为男性）中，1072 名（86%）为单纯 AR，167 名（14%）为 AR+MR（9%为功能性二尖瓣反流[FMR] [84%非缺血性]，5%为器质性二尖瓣反流[OMR] [62%退行性]）。在基线经胸超声心动图中，单纯 AR 与 AR+OMR 相比，AR+FMR 在年龄（59±18、62±16 和 73±14 岁）、女性（18%、27%和 39%）、症状（36%、41%和 64%）、心房颤动（5%、17%和 36%）、左心室（LV）射血分数（59%、58%和 46%）、LV 收缩末期内径和容量指数、≥中度三尖瓣反流（TR）（7%、35%和 53%）和右心室收缩压（32±11、45±15 和 50±14mmHg）方面存在差异，所有差异均有统计学意义（p均<0.0001）。中位随访 5.2 年（四分位距：2.2 至 10.0 年）后，调整人口统计学、纽约心脏协会功能分级、主动脉瓣手术、LV 射血分数、LV 收缩末期内径和容量指数后，FMR 与全因死亡率独立相关（p均≤0.004）。与单纯 AR 相比，AR+MR+TR 的调整死亡风险最高（2.4 倍；p<0.0001）。与预期人群生存率相比，单纯 AR、AR+OMR 和 AR+FMR 的超额死亡率分别为 1.25 倍、1.76 倍和 2.34 倍（均 p≤0.02）。
在血流动力学显著的 AR 中，并存的 MR 并不少见（约 14%），主要由 FMR 引起，其次是 OMR。与单纯 AR 相比，AR+MR+TR 的死亡率风险最大。与一般人群相比，AR+OMR 和 AR+FMR 的生存率均受到影响，但 AR+FMR 与最大的超额死亡率相关，代表 AR 临床谱中的晚期阶段。
