Severe mitral regurgitation (MR) is common in patients with significant aortic regurgitation (AR) and that patients with multiple regurgitant lesions risk a 2.4-fold increase in the risk of death, according to a study published Monday.
The study by Li-Tan Yang, MD, of the Mayo Clinic, Rochester, Minnesota, and colleagues was published in the July 21 issue of the Journal of the American College of Cardiology.
While it is known that patients with isolated AR have an increased mortality rate, most studies examining the natural history of the disease have excluded patients with coexistent MR, leaving a significant knowledge gap. The authors sought to address this by investigating the prevalence, mechanisms, etiologies and survival impact of coexistent MR (moderate or greater) in AR patients.
The investigators used the echocardiographic database at the Mayo Clinic to identify 1,239 patients with greater than moderate AR. Within this cohort, 167 (14%) patients had moderate or greater MR. The mechanism driving the MR was functional in 9% of patients and organic in 5%. The investigators discovered that patients with functional MR tended to be older, women, more likely to have atrial fibrillation and more likely to have lower left ventricular ejection fractions. Furthermore, the investigators discovered that over the 5 years of follow-up, the patients with AR and functional MR had a 2.34-fold increased risk of mortality when compared to the expected population survival.
The authors put the results in context, highlighting that the “pathophysiological hallmark in patients with AR is a dilated left ventricle, which may tether mitral leaflets, resulting in functional mitral regurgitation (FMR)” suggesting that “FMR represents an advanced stage within the AR clinical spectrum, with more advanced LV and LA remodeling, AF, pulmonary hypertension and TR, and it is associated with excess death independently of LVEF, LVESDi (left ventricular end-systolic diameter index) and LV end-systolic volume index.”
An accompanying editorial by Christophe Tribouilloy, MD, PhD, of Amiens University Hospital, France, and colleagues praised the authors’ work stating: “The study by Yang et al. provides an important addition to the body of knowledge required to respond to the challenges imposed by multi-valvular heart disease. More data on the natural history and impact of surgery on outcomes, especially in asymptomatic patients, are required to better define the indications, type, and timing of valve interventions.”
In the interim, the editorialists recommended that “these patients should be followed in heart valve centers, with a case-by-case management strategy determined by the heart team, considering the severity of each lesion and the risk of the intervention, taking into account the age, comorbidities, and frailty of the patient, as well as the natural history of each valve lesion if left untreated.
“Undoubtedly, advances in transcatheter valve therapies will change the management paradigm of multi-valvular heart disease in the near future, but definitive data are still lacking,” Tribouilloy and colleagues wrote.
Yang LT, Enriquez-Sarano M, Scott CG, et al. Concomitant Mitral Regurgitation in Patients With Chronic Aortic Regurgitation. J Am Coll Cardiol 2020;76:233-46. https://doi.org/10.1016/j.jacc.2020.05.051
Tribouilloy C, Bohbot Y, Unger P. Mitral Regurgitation in Patients With Severe Aortic Regurgitation: When Misery Loves Company. J Am Coll Cardiol 2020;76:247-50. https://doi.org/10.1016/j.jacc.2020.05.055