Berrill Max, Beeton Ian, Fluck David, John Isaac, Lazariashvili Otar, Stewart Jack, Ashcroft Eshan, Belsey Jonathan, Sharma Pankaj, Baltabaeva Aigul
Department of Cardiology, St. Peter's Hospital, Surrey, United Kingdom.
Department of Research and Development, St. Peter's Hospital, Surrey, United Kingdom.
Front Cardiovasc Med. 2021 Dec 2;8:742224. doi: 10.3389/fcvm.2021.742224. eCollection 2021.
To assess the prevalence and impact of mitral regurgitation (MR) on survival in patients presenting to hospital in acute heart failure (AHF) using traditional echocardiographic assessment alongside more novel indices of proportionality. It remains unclear if the severity of MR plays a significant role in determining outcomes in AHF. There is also uncertainty as to the clinical relevance of indexing MR to left ventricular volumes. This concept of disproportionality has not been assessed in AHF. A total of 418 consecutive patients presenting in AHF over 12 months were recruited and followed up for 2 years. MR was quantitatively assessed within 24 h of recruitment. Standard proximal isovelocity surface area (PISA) and a novel proportionality index of effective regurgitant orifice/left ventricular end-diastolic volume (ERO/LVEDV) >0.14 mm/ml were used to identify severe and disproportionate MR. Every patient had MR. About 331/418 (78.9%) patients were quantifiable by PISA. About 165/418 (39.5%) patients displayed significant MR. A larger cohort displayed disproportionate MR defined by either a proportionality index using ERO/LVEDV > 0.14 mm/ml or regurgitant volumes/LVEDV > 0.2 [217/331 (65.6%) and 222/345 (64.3%), respectively]. The LVEDV was enlarged in significant MR-129.5 ± 58.95 vs. 100.0 ± 49.91 ml in mild, [ < 0.0001], but remained within the normal range. Significant MR was associated with a greater mortality at 2 years {44.2 vs. 34.8% in mild MR [hazard ratio (HR) 1.39; 95% CI: 1.01-1.92, = 0.04]}, which persisted with adjustment for comorbid conditions (HR; 1.43; 95% CI: 1.04-1.97, = 0.03). Disproportionate MR defined by ERO/LVEDV >0.14 mm/ml was also associated with worse outcome [42.4 vs. 28.3% (HR 1.62; 95% CI 1.12-2.34, = 0.01)]. MR was a universal feature in AHF and determines outcome in significant cases. Furthermore, disproportionate MR, defined either by effective regurgitant orifice (ERO) or volumetrically, is associated with a worse prognosis despite the absence of adverse left ventricular (LV) remodeling. These findings outline the importance of adjusting acute volume overload to LV volumes and call for a review of the current standards of MR assessment. https://clinicaltrials.gov/ct2/show/NCT02728739, identifier NCT02728739.
采用传统超声心动图评估方法以及更新颖的比例指标，评估二尖瓣反流（MR）在急性心力衰竭（AHF）住院患者中的患病率及其对生存的影响。目前尚不清楚MR的严重程度在决定AHF患者的预后方面是否起重要作用。将MR与左心室容积进行指数化的临床相关性也存在不确定性。这种不成比例的概念在AHF中尚未得到评估。共招募了418例在12个月内出现AHF的连续患者，并进行了2年的随访。在招募后24小时内对MR进行定量评估。使用标准近端等速表面积（PISA）和有效反流口面积/左心室舒张末期容积（ERO/LVEDV）>0.14 mm/ml的新型比例指标来识别严重和不成比例的MR。所有患者均有MR。约331/418（78.9%）例患者可通过PISA进行量化。约165/418（39.5%）例患者表现出显著MR。更大的队列显示出由ERO/LVEDV>0.14 mm/ml的比例指标或反流容积/LVEDV>0.2定义的不成比例MR[分别为217/331（65.6%）和222/345（64.3%）]。在显著MR患者中左心室舒张末期容积增大——严重MR患者为129.5±58.95 ml，轻度MR患者为100.0±49.91 ml，[P<0.0001]，但仍在正常范围内。显著MR与2年时更高的死亡率相关{轻度MR患者为44.2%，而轻度MR患者为34.8%[风险比（HR）1.39；95%置信区间：1.01 - 1.92，P = 0.04]}，在对合并症进行调整后该相关性仍然存在（HR；1.43；95%置信区间：1.04 - 1.97，P = 0.03）。由ERO/LVEDV>0.14 mm/ml定义的不成比例MR也与更差的预后相关[42.4%对28.3%（HR 1.62；95%置信区间1.12 - 2.34，P = 0.01）]。MR是AHF的普遍特征，并在显著病例中决定预后。此外，无论是否存在不良左心室（LV）重构，由有效反流口面积（ERO）或容积定义的不成比例MR均与更差的预后相关。这些发现凸显了将急性容量超负荷调整至左心室容积的重要性，并呼吁对当前MR评估标准进行审查。https://clinicaltrials.gov/ct2/show/NCT02728739，标识符NCT02728739
