Hamid Nadira, Bursi Francesca, Benfari Giovanni, Vanoverschelde Jean-Louis, Tribouilloy Christophe, Biagini Elena, Avierinos Jean-Francois, Barbieri Andrea, Fan Yiting, Guerra Federico, Leng Chua Yeow, Essayagh Benjamin, Pasquet Agnés, Szymansky Catherine, Théron Alexis, Michelena Hector I, Nkomo Vuyisile T, Vancraeynest David, Rusinaru Dan, Grigioni Francesco, Enriquez-Sarano Maurice L, Pin Ding Zee, Pui-Wai Lee Alex
National Heart Centre Singapore, Singapore.
New York Presbyterian Hospital, Columbia University Medical Center, New York, New York.
JACC Asia. 2024 May 21;4(6):468-480. doi: 10.1016/j.jacasi.2024.03.003. eCollection 2024 Jun.
Clinical outcome and interventional thresholds for degenerative mitral regurgitation (DMR) were developed in studies of patients at European and American institutions (EAIs), but little is known about patients at Asian institutions (AsIs).
This study sought to contrast DMR presentation/management/outcomes of AsI patients vs EAI patients.
Patients with DMR due to flail leaflet from Hong Kong and Singapore (AsI cohort, n = 737) were compared with EAI patients (n = 682) enrolled in the MIDA (Mitral regurgitation International Database) registry with similar eligibility criteria.
AsI patients presented similar DMR lesion/consequences vs EAI patients, but they were younger, with fewer symptoms (74% vs 44% Class I), more sinus rhythm (83% vs 69%), and lower EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) (0.9 ± 0.5 vs 1.4 ± 1.5; all < 0.0001). Imaging showed smaller absolute left atrial/ventricular dimensions in AsI patients, belying cardiac dilatation with larger body surface area-indexed diameters (all < 0.01). Surgical/interventional mitral repair was similarly predominant (90% vs 91%; = 0.47), and early repair was similarly beneficial (for AsI patients, adjusted HR: 0.28; 95% CI: 0.16-0.49; for EAI patients, HR: 0.32; 95% CI: 0.20-0.49; both < 0.0001). However, AsI patients underwent fewer interventions (55% ± 2% vs 77% ± 2% at 1 year; < 0.0001) and incurred excess mortality (adjusted HR: 1.60 [95% CI: 1.13-2.27] vs EAI patients; = 0.008) at long-term postdiagnosis. Propensity score matching (434 patient pairs), which balanced all clinical characteristics, confirmed that there was undertreatment and excess mortality in the long term in AsI patients with DMR ( < 0.0001).
Imaging may underestimate volume overload in AsI patients due to smaller cardiac cavities related to smaller body size compared with EAI patients with similar mitral lesions and DMR severity. AsI patients enjoy similar mitral repair predominance and early intervention benefits but undergo fewer mitral interventions than EAI patients and incur subsequent excess mortality, suggesting the need to account for imaging and cultural specificity to improve DMR outcomes worldwide.
退行性二尖瓣反流（DMR）的临床结局和干预阈值是在欧美机构（EAIs）对患者的研究中得出的，但对于亚洲机构（AsIs）的患者了解甚少。
本研究旨在对比亚洲机构患者与欧美机构患者的DMR表现/管理/结局。
将来自中国香港和新加坡的因瓣叶脱垂导致DMR的患者（亚洲队列，n = 737）与入选二尖瓣反流国际数据库（MIDA）登记处、具有相似纳入标准的欧美机构患者（n = 682）进行比较。
亚洲机构患者与欧美机构患者的DMR病变/后果相似，但亚洲机构患者更年轻，症状更少（Ⅰ级者占74% vs 44%），窦性心律更多（83% vs 69%），欧洲心脏手术风险评估系统Ⅱ（EuroSCORE II）更低（0.9±0.5 vs 1.4±1.5；均P<0.0001）。影像学检查显示亚洲机构患者的左心房/心室绝对尺寸较小，尽管按体表面积指数计算的直径较大，提示存在心脏扩大（均P<0.01）。外科/介入性二尖瓣修复同样占主导（90% vs 91%；P = 0.47），早期修复同样有益（对于亚洲机构患者，校正后HR：0.28；95%CI：0.16 - 0.49；对于欧美机构患者，HR：0.32；95%CI：0.20 - 0.49；均P<0.0001）。然而，亚洲机构患者接受的干预较少（1年时为55%±2% vs 77%±2%；P<0.0001），且在诊断后的长期随访中死亡率过高（校正后HR：1.60[95%CI：1.13 - 2.27]，与欧美机构患者相比；P = 0.008）。倾向评分匹配（434对患者）平衡了所有临床特征，证实亚洲机构DMR患者长期存在治疗不足和死亡率过高的情况（P<0.0001）。
与具有相似二尖瓣病变和DMR严重程度的欧美机构患者相比，由于体型较小导致心脏腔室较小，影像学检查可能低估了亚洲机构患者的容量超负荷情况。亚洲机构患者二尖瓣修复同样占主导且早期干预有益，但二尖瓣干预比欧美机构患者少，随后死亡率过高，这表明需要考虑影像学和文化特异性以改善全球DMR的结局。
