RESUMEN
Importance: The characteristics and treatment strategies of atrial functional mitral regurgitation (AFMR) are poorly understood. Objective: To investigate the prevalence, clinical characteristics, and outcomes of mitral valve (MV) surgery in AFMR. Design, Setting, and Participants: This retrospective cohort study, called the Real-World Observational Study for Investigating the Prevalence and Therapeutic Options for Atrial Functional Mitral Regurgitation (REVEAL-AFMR), was conducted across 26 Japanese centers (17 university hospitals, 1 national center, 3 public hospitals, and 5 private hospitals). All transthoracic echocardiography procedures performed from January 1 to December 31, 2019, were reviewed to enroll adult patients (aged ≥20 years) with moderate or severe AFMR, defined by preserved left ventricular function, a dilated left atrium, and an absence of degenerative valvular changes. Data were analyzed from May 8, 2023, to May 16, 2024. Exposures: Mitral valve surgery, with or without tricuspid valve intervention. Main Outcomes and Measures: The primary composite outcome included heart failure hospitalization and all-cause mortality. Results: In 177â¯235 patients who underwent echocardiography, 8867 had moderate or severe MR. Within this group, 1007 (11.4%) were diagnosed with AFMR (mean [SD] age, 77.8 [9.5] years; 55.7% female), of whom 807 (80.1%) had atrial fibrillation. Of these patients, 113 underwent MV surgery, with 92 (81.4%) receiving concurrent tricuspid valve surgery. Patients who underwent surgery were younger but had more severe MR (57.5% [n = 65] vs 9.4% [n = 84]; P < .001), a larger mean (SD) left atrial volume index (152.5 [97.8] mL/m2 vs 87.7 [53.1] mL/m2; P < .001), and a higher prevalence of heart failure (according to the New York Heart Association class III [marked limitation of physical activity] or class IV [symptoms of heart failure at rest], 26.5% [n = 30] vs 9.3% [n = 83]; P < .001) than those who remained under medical therapy. During a median follow-up of 1050 days (IQR, 741-1188 days), 286 patients (28.4%) experienced the primary outcome. Despite a more severe disease status, only the surgical group showed a decrease in natriuretic peptide levels at follow-up and had a significantly lower rate of the primary outcome (3-year event rates were 18.3% vs 33.3%; log-rank, P = .03). Statistical adjustments did not alter these findings. Conclusions and Relevance: The findings of this cohort study suggest that in patients with AFMR, who were typically older and predominantly had atrial fibrillation, MV surgery was associated with lower rates of adverse clinical outcomes. Future studies are warranted to investigate a possible causal relationship to better regulate cardiovascular medicine.
Asunto(s)
Insuficiencia de la Válvula Mitral , Válvula Mitral , Sistema de Registros , Humanos , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Femenino , Masculino , Anciano , Estudios Retrospectivos , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Anciano de 80 o más Años , Resultado del Tratamiento , Persona de Mediana Edad , Japón/epidemiología , Ecocardiografía , Atrios Cardíacos/fisiopatología , Atrios Cardíacos/diagnóstico por imagenRESUMEN
In this study, we hypothesized that post-operative aorto-mitral angle might be associated to the occurrence of post-operative atrial arrhythmia (AA), including atrial fibrillation and atrial tachycardia, after mitral valve repair in patients with mitral regurgitation (MR). Thus, this present study aims to determine the effects of post-operative aorto-mitral angle on new-onset AA after mitral valve repair with mitral annuloplasty for the treatment of MR.In total, 172 patients without any history of AA underwent mitral valve repair with mitral annuloplasty in our institution between 2008 and 2017. Patient information, including medical records and echocardiographic data, were retrospectively studied.As per our findings, AA occurred in 15 (8.7%) patients during the follow-up period (median, 35.7 months; range, 0.5-132 months). The patients with AA were noted to have a longer cardiopulmonary bypass time and a smaller aorto-mitral angle at post-operative TTE than the others (119 ± 6° versus 125 ± 10°, P = 0.003). No significant difference was noted in the degree of post-operative residual MR or functional MS between the groups. In a multivariate Cox proportional hazards analysis, the longer cardiopulmonary bypass time and the smaller post-operative aorto-mitral angle were independent predictors of the occurrence of AA during the follow-up period (odds ratio per 10 minutes 1.11; 95% CI 1.02-1.22, P = 0.019: odds ratio 0.91; 95% CI 0.85-0.98, P = 0.012).A small aorto-mitral angle at post-operative TTE was determined to be a predictor of new-onset AA after a mitral valve repair for treating MR.
Asunto(s)
Válvula Aórtica/diagnóstico por imagen , Fibrilación Atrial/etiología , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Taquicardia/etiología , Puente Cardiopulmonar , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
BACKGROUND: Dobutamine stress echocardiography (DSE) is required to determine whether low-gradient aortic stenosis (AS) with a small aortic valve area (AVA) is truly severe. The purpose of the present study was to evaluate the usefulness of ejection dynamics parameters at resting echocardiography for predicting the result of DSE performed in patients with low-gradient AS. METHODS: The results of resting echocardiography and DSE performed on 51 AS patients with low mean-gradient (<40 mmHg) and small indexed AVA (<0.60 cm2/m2) were retrospectively reviewed. Acceleration time (AT) and the ratio of AT to ejection time (ET) were measured on the recorded images. True-severe AS was defined as that with indexed projected AVA < 0.60 cm2/m2. RESULTS: Twenty-six (51%) patients had true-severe AS, while 22 (43%) patients had preserved left ventricular ejection fraction (≥50%). Baseline indexed AVA and AT/ET were independently associated with indexed projected AVA at DSE. AT/ET was the only independent determinant of valve compliance. Indexed AVA ≤ 0.493 cm2/m2 and AT/ET > 0.334 at baseline had sensitivities of 69% and 65% and specificities of 84% and 84%, respectively, for predicting true-severe AS. The presence of either indexed AVA ≤ 0.493 cm2/m2 or AT/ET > 0.334 had a higher sensitivity (88%), and their co-occurrence had a higher specificity (100%). CONCLUSIONS: Indexed projected AVA at DSE was predicted by AT/ET, which represented valve compliance, along with indexed AVA. The true severity of low-gradient AS can be screened using a combination of resting indexed AVA and AT/ET without performing DSE.