A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation
Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate. The current study aimed to define improved risk-thresholds specif...
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| Veröffentlicht in: | Journal of the American College of Cardiology 2019-05, Vol.73 (20), p.2506-2517 |
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| creator | Bartko, Philipp E. Arfsten, Henrike Heitzinger, Gregor Pavo, Noemi Toma, Aurel Strunk, Guido Hengstenberg, Christian Hülsmann, Martin Goliasch, Georg |
| description | Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate.
The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy.
This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac).
Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA |
| doi_str_mv | 10.1016/j.jacc.2019.02.075 |
| format | Article |
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The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy.
This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac).
Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms.
Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading.
[Display omitted]</description><identifier>ISSN: 0735-1097</identifier><identifier>EISSN: 1558-3597</identifier><identifier>DOI: 10.1016/j.jacc.2019.02.075</identifier><identifier>PMID: 31118144</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Aged ; Algorithms ; Beta blockers ; Cardiology ; Confidence intervals ; Congestive heart failure ; Echocardiography, Doppler, Color - methods ; Echocardiography, Three-Dimensional - methods ; effective regurgitant orifice area ; Evaluation ; Female ; Follow-Up Studies ; Heart ; Heart failure ; Heart Failure - diagnosis ; Heart Failure - etiology ; Heart Failure - physiopathology ; heart failure with reduced ejection fraction ; Hemodynamics ; Humans ; Integrated approach ; Laboratories ; Male ; Middle Aged ; mitral insufficiency ; Mitral Valve - diagnostic imaging ; Mitral Valve Insufficiency - complications ; Mitral Valve Insufficiency - diagnosis ; Mitral Valve Insufficiency - physiopathology ; Mortality ; Orifices ; proximal isovelocity surface area ; Pulmonary arteries ; regurgitant fraction ; regurgitant volume ; Regurgitation ; Risk assessment ; Risk Factors ; Risk groups ; secondary mitral regurgitation ; Severity of Illness Index ; Software ; Statistical analysis ; Stroke Volume ; Thoracic surgery ; Thresholds ; Ventricular Function, Left - physiology</subject><ispartof>Journal of the American College of Cardiology, 2019-05, Vol.73 (20), p.2506-2517</ispartof><rights>2019 American College of Cardiology Foundation</rights><rights>Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.</rights><rights>2019. American College of Cardiology Foundation</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c384t-e0c0368d4ffdb23357a16a9eb6a6788b840d3ff1cae75dd48b6c168f8f44d1bc3</citedby><cites>FETCH-LOGICAL-c384t-e0c0368d4ffdb23357a16a9eb6a6788b840d3ff1cae75dd48b6c168f8f44d1bc3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S0735109719347175$$EHTML$$P50$$Gelsevier$$Hfree_for_read</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31118144$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bartko, Philipp E.</creatorcontrib><creatorcontrib>Arfsten, Henrike</creatorcontrib><creatorcontrib>Heitzinger, Gregor</creatorcontrib><creatorcontrib>Pavo, Noemi</creatorcontrib><creatorcontrib>Toma, Aurel</creatorcontrib><creatorcontrib>Strunk, Guido</creatorcontrib><creatorcontrib>Hengstenberg, Christian</creatorcontrib><creatorcontrib>Hülsmann, Martin</creatorcontrib><creatorcontrib>Goliasch, Georg</creatorcontrib><title>A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation</title><title>Journal of the American College of Cardiology</title><addtitle>J Am Coll Cardiol</addtitle><description>Diverging guideline definitions for the quantitative assessment of severe secondary mitral regurgitation (sMR) reflect the lacking link of the sMR spectrum to mortality and has introduced a source of uncertainty and continuing debate.
The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy.
This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac).
Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms.
Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading.
[Display omitted]</description><subject>Aged</subject><subject>Algorithms</subject><subject>Beta blockers</subject><subject>Cardiology</subject><subject>Confidence intervals</subject><subject>Congestive heart failure</subject><subject>Echocardiography, Doppler, Color - methods</subject><subject>Echocardiography, Three-Dimensional - methods</subject><subject>effective regurgitant orifice area</subject><subject>Evaluation</subject><subject>Female</subject><subject>Follow-Up Studies</subject><subject>Heart</subject><subject>Heart failure</subject><subject>Heart Failure - diagnosis</subject><subject>Heart Failure - etiology</subject><subject>Heart Failure - physiopathology</subject><subject>heart failure with reduced ejection fraction</subject><subject>Hemodynamics</subject><subject>Humans</subject><subject>Integrated approach</subject><subject>Laboratories</subject><subject>Male</subject><subject>Middle Aged</subject><subject>mitral insufficiency</subject><subject>Mitral Valve - diagnostic imaging</subject><subject>Mitral Valve Insufficiency - complications</subject><subject>Mitral Valve Insufficiency - diagnosis</subject><subject>Mitral Valve Insufficiency - physiopathology</subject><subject>Mortality</subject><subject>Orifices</subject><subject>proximal isovelocity surface area</subject><subject>Pulmonary arteries</subject><subject>regurgitant fraction</subject><subject>regurgitant volume</subject><subject>Regurgitation</subject><subject>Risk assessment</subject><subject>Risk Factors</subject><subject>Risk groups</subject><subject>secondary mitral regurgitation</subject><subject>Severity of Illness Index</subject><subject>Software</subject><subject>Statistical analysis</subject><subject>Stroke Volume</subject><subject>Thoracic surgery</subject><subject>Thresholds</subject><subject>Ventricular Function, Left - physiology</subject><issn>0735-1097</issn><issn>1558-3597</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kEtuFDEURS0EIk1gAwxQSUyYVOFPueySmLRa4SMFIT5harns58albruxXZGym6wlK8NNBwYMGL3JuVf3HYSeE9wRTIbXczdrYzqKydhh2mHBH6AV4Vy2jI_iIVphwXhL8CjO0JOcZ4zxIMn4GJ0xQogkfb9C39fNVfDuxodts4nBwKE0Lqam_IDm86JD8UUXfw13t-ucIec9hNJE13wFE4PV6ebu9qMvSe-aL7Bd0vY3HsNT9MjpXYZn9_ccXb29-LZ5315-evdhs75sDZN9aQEbzAZpe-fsRBnjQpNBjzANehBSTrLHljlHjAbBre3lNBgySCdd31syGXaOXp16Dyn-XCAXtffZwG6nA8QlK0oZJRhTziv68h90jksKdV2lqBCjwHKsFD1RJsWcEzh1SH5f_1QEq6N1NaujdXW0rjBV1XoNvbivXqY92L-RP5or8OYEQHVx7SGpbDxU29YnMEXZ6P_X_ws7OpUD</recordid><startdate>20190528</startdate><enddate>20190528</enddate><creator>Bartko, Philipp E.</creator><creator>Arfsten, Henrike</creator><creator>Heitzinger, Gregor</creator><creator>Pavo, Noemi</creator><creator>Toma, Aurel</creator><creator>Strunk, Guido</creator><creator>Hengstenberg, Christian</creator><creator>Hülsmann, Martin</creator><creator>Goliasch, Georg</creator><general>Elsevier Inc</general><general>Elsevier Limited</general><scope>6I.</scope><scope>AAFTH</scope><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7T5</scope><scope>7TK</scope><scope>H94</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope></search><sort><creationdate>20190528</creationdate><title>A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation</title><author>Bartko, Philipp E. ; 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The current study aimed to define improved risk-thresholds specifically tailored to the complex nature of sMR that provide a unifying solution to the ongoing guideline-controversy.
This study enrolled 423 heart failure patients under guideline-directed medical therapy and assessed sMR by effective regurgitant orifice area (EROA), regurgitant volume (RegVol), and regurgitant fraction (RegFrac).
Measures of sMR severity were consistently associated with 5-year mortality with a hazard ratio of 1.42 for a 1-SD increase (95% confidence interval [CI]: 1.25 to 1.63; p < 0.001) for EROA, 1.37 (95% CI: 1.20 to 1.56; p < 0.001) for RegVol, and 1.50 (95% CI: 1.30 to 1.73; p < 0.001) for RegFrac. Results remained statistically significant after bootstrap- or clinical confounder-based adjustment. Spline-curve analyses showed a linearly increasing risk enabling the ability to stratify into low-risk (EROA <20 mm2 and RegVol <30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml), and high-risk (EROA ≥30 mm2 and RegVol ≥45 ml) groups. In the intermediate-risk group, a RegFrac ≥50% as indicator for hemodynamic severe sMR was associated with poor outcome (p = 0.017). A unifying concept based on combined assessment of the EROA, the RegVol, and the RegFrac showed a significantly better discrimination compared with the currently established algorithms.
Risk-based thresholds tailored to the pathophysiological concept of sMR provide a unifying solution to the ongoing guideline controversy. An algorithm based on the combined assessment of the unifying cutoffs for EROA, RegVol, and RegFrac improves risk prediction compared with currently established grading.
[Display omitted]</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>31118144</pmid><doi>10.1016/j.jacc.2019.02.075</doi><tpages>12</tpages><oa>free_for_read</oa></addata></record> |
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| subjects | Aged Algorithms Beta blockers Cardiology Confidence intervals Congestive heart failure Echocardiography, Doppler, Color - methods Echocardiography, Three-Dimensional - methods effective regurgitant orifice area Evaluation Female Follow-Up Studies Heart Heart failure Heart Failure - diagnosis Heart Failure - etiology Heart Failure - physiopathology heart failure with reduced ejection fraction Hemodynamics Humans Integrated approach Laboratories Male Middle Aged mitral insufficiency Mitral Valve - diagnostic imaging Mitral Valve Insufficiency - complications Mitral Valve Insufficiency - diagnosis Mitral Valve Insufficiency - physiopathology Mortality Orifices proximal isovelocity surface area Pulmonary arteries regurgitant fraction regurgitant volume Regurgitation Risk assessment Risk Factors Risk groups secondary mitral regurgitation Severity of Illness Index Software Statistical analysis Stroke Volume Thoracic surgery Thresholds Ventricular Function, Left - physiology |
| title | A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation |
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