Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.
Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea.
Am J Cardiol. 2023 Jul 15;199:25-32. doi: 10.1016/j.amjcard.2023.04.040. Epub 2023 May 23.
The classification of secondary mitral regurgitation (MR) is based on atrial functional MR (AFMR) or ventricular functional MR (VFMR) and volume changes, but the mitral leaflet coaptation angle also contributes to the MR mechanism. The clinical implications of the coaptation angle on cardiovascular (CV) outcomes have not been well evaluated. A total of 469 consecutive patients (265 AFMR vs 204 VFMR) with more than moderate MR were evaluated for the occurrence of heart failure, mitral valve operations, and CV death. The coaptation angle was assessed by measuring the internal angle between both leaflets at mid-systole using the apical 3-chamber view. A coaptation angle ≥130° was classified as leaflet flattening, and an angle <130° was classified as leaflet tethering. AFMR and VFMR were associated with higher frequencies of leaflet flattening and tethering, respectively. AFMR was more likely to be associated with older age, atrial fibrillation, and preserved ejection fraction, all of which were related to leaflet flattening. During a follow-up of 2.3 years, 83 patients had heart failure (17.7%), 21 patients underwent mitral valve operations (4.5%), and 34 patients died (7%). Compared with leaflet tethering, leaflet flattening was more significantly related to CV events, whereas CV event rates were less markedly different in A/VFMR. Irrespective of A/VFMR, leaflet flattening and atrial fibrillation were associated with a higher frequency of CV events. Adjusted analysis showed that leaflet flattening remained an independent predictor of CV events (hazard ratio 3.5, 95% confidence interval 1.11 to 4.88, p = 0.003), whereas A/VFMR did not. In conclusion, the leaflet coaptation angle in patients with functional MR could provide risk stratification superior to that of A/VFMR. Leaflet flattening appears to be associated with unfavorable clinical outcomes.
功能性二尖瓣反流（MR）的分类基于心房功能性 MR（AFMR）或心室功能性 MR（VFMR）和容量变化，但二尖瓣瓣叶的对合角度也有助于 MR 机制。瓣叶对合角度对心血管（CV）结局的临床意义尚未得到很好的评估。共有 469 例连续患者（265 例 AFMR 与 204 例 VFMR），其 MR 程度超过中度，评估心力衰竭、二尖瓣手术和 CV 死亡的发生情况。使用心尖 3 腔视图测量收缩中期两个瓣叶之间的内夹角来评估对合角度。将瓣叶平坦度≥130°分类为瓣叶变平，角度<130°分类为瓣叶牵张。AFMR 和 VFMR 分别与更高的瓣叶平坦度和牵张度相关。AFMR 更可能与年龄较大、心房颤动和射血分数保留有关，所有这些都与瓣叶变平有关。在 2.3 年的随访期间，83 例患者发生心力衰竭（17.7%），21 例患者接受了二尖瓣手术（4.5%），34 例患者死亡（7%）。与瓣叶牵张相比，瓣叶变平与 CV 事件的相关性更为显著，而在 A/VFMR 中 CV 事件发生率差异不大。无论 A/VFMR 如何，瓣叶变平和心房颤动与更高的 CV 事件频率相关。调整分析表明，瓣叶变平仍然是 CV 事件的独立预测因素（危险比 3.5，95%置信区间 1.11 至 4.88，p=0.003），而 A/VFMR 则不是。总之，功能性 MR 患者的瓣叶对合角度可提供优于 A/VFMR 的风险分层。瓣叶变平似乎与不良的临床结局相关。
