Sarrazyn Camille, Fortuni Federico, Laenens Dorien, Chua Aileen Paula, Lopez Santi Maria Pilar, Myagmardorj Rinchyenkhand, Nabeta Takeru, Meucci Maria Chiara, Singh Gurpreet Kaur, Velders Bart Josephus Johannes, Galloo Xavier, Bax Jeroen Joost, Ajmone Marsan Nina
Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.
Cardiology, Ospedale Nuovo San Giovanni Battista, Foligno, Italy.
Heart. 2024 Dec 13;111(1):35-42. doi: 10.1136/heartjnl-2024-324526.
Significant secondary mitral regurgitation (SMR) is known to be associated with worse prognosis. However, data focusing specifically on moderate SMR and associated risk factors are lacking. In the present study, clinical and echocardiographic parameters associated with outcomes were evaluated in a large cohort of patients with moderate SMR.
Patients with moderate SMR were retrospectively included and stratified by New York Heart Association (NYHA) class and specific aetiology (atrial SMR (aSMR) or ventricular SMR (vSMR)) with a further classification of vSMR based on left ventricular ejection fraction (LVEF) ≥40% or <40%. The primary endpoint was all-cause mortality and the secondary endpoint was the composite of all-cause mortality and heart failure (HF) events.
Of the total 1061 patients with moderate SMR (age 69±11 years, 59% male) included, 854 (80%) were in NYHA class I-II and 207 (20%) were in NYHA class III-IV. Regarding the aetiology, 352 (33%) had aSMR and 709 (67%) had vSMR, of which 329 (46%) had LVEF ≥40% and 380 (54%) had LVEF <40%. During a median follow-up of 82 (IQR 55-115) months, 397 (37%) died and 539 (51%) patients had HF events or died. On multivariable analysis, NYHA class III-IV (HR 1.578; 95% CI 1.244 to 2.002, p<0.001) and SMR aetiology were independently associated with both endpoints. Specifically, compared to aSMR, vSMR with LVEF ≥40% had a HR of 1.528 (95% CI 1.108 to 2.106, p=0.010) and vSMR with LVEF <40% had a HR of 1.960 (95% CI 1.434 to 2.679, p<0.001). To further support these findings, patients were matched for (1) NYHA class and (2) SMR aetiology by propensity scores including age, sex, diabetes, chronic obstructive pulmonary disease, renal function, left atrial volume index, NYHA class (only for SMR aetiology matching), LVEF, SMR aetiology (only for NYHA class matching), tricuspid regurgitation severity and right ventricular pulmonary artery coupling index. After matching, NYHA class and SMR aetiology remained associated with both outcomes (for both: log rank p<0.050).
In patients with moderate SMR, distinction in SMR aetiology and assessment of symptoms are important independent determinants of outcome.
严重继发性二尖瓣反流（SMR）已知与更差的预后相关。然而，缺乏专门针对中度SMR及其相关危险因素的数据。在本研究中，我们在一大群中度SMR患者中评估了与预后相关的临床和超声心动图参数。
回顾性纳入中度SMR患者，并根据纽约心脏协会（NYHA）分级和特定病因（心房性SMR（aSMR）或心室性SMR（vSMR））进行分层，vSMR再根据左心室射血分数（LVEF）≥40%或<40%进一步分类。主要终点是全因死亡率，次要终点是全因死亡率和心力衰竭（HF）事件的复合终点。
在纳入的总共1061例中度SMR患者中（年龄69±11岁，59%为男性），854例（80%）为NYHA I-II级，207例（20%）为NYHA III-IV级。关于病因，352例（33%）有aSMR，709例（67%）有vSMR，其中329例（46%）LVEF≥40%，380例（54%）LVEF<40%。在中位随访82（IQR 55-115）个月期间，397例（37%）死亡，539例（51%）患者发生HF事件或死亡。多变量分析显示，NYHA III-IV级（HR 1.578；95%CI 1.244至2.002， p<0.001）和SMR病因与两个终点均独立相关。具体而言，与aSMR相比，LVEF≥40%的vSMR的HR为1.528（95%CI 1.108至2.106， p=0.010），LVEF<40%的vSMR的HR为1.960（95%CI 1.434至2.679， p<0.001）。为进一步支持这些发现，通过倾向评分对患者进行匹配，倾向评分包括年龄、性别、糖尿病、慢性阻塞性肺疾病、肾功能、左心房容积指数、NYHA分级（仅用于SMR病因匹配）、LVEF、SMR病因（仅用于NYHA分级匹配）、三尖瓣反流严重程度和右心室肺动脉耦合指数。匹配后，NYHA分级和SMR病因仍与两个结局相关（两者：对数秩检验p<0.050）。
在中度SMR患者中，SMR病因的区分和症状评估是结局的重要独立决定因素。
