Functional mitral regurgitation in dilated cardiomyopathy: clinical implications and prognosis

Abstract Funding Acknowledgements Type of funding sources: None. Dilated cardiomyopathy (DCM) is a complex myocardial disease, with a high burden of symptoms and decreased life expectancy. Mitral regurgitation (MR) is a frequent comorbid condition and it is thought that it deteriorates left ventricle (LV) volume and ejection fraction. Guideline directed medical therapy for heart failure improves myocardial function and decreases morbidity and mortality, and there is ongoing interest in the application of novel percutaneous techniques like mitral edge-to-edge repair or resynchronization therapy in order to decrease cardiovascular events (CVE). Our objective was to analyze if MR is associated with late gadolinium enhancement (LGE), left ventricle (LV) or right ventricle (RV) dysfunction and cardiovascular events in patients with DCM. A retrospective, case control study was designed including 173 patients (mean age 60 years, 73% males, 36% dyslipemia, 30% diabetes, 20% hypertension, 8% current smokers) with diagnosis of DCM and cardiac magnetic resonance study in our center between 2014-2020 according to the latest European Society of Cardiology (ESC) definition and the latest updated position paper. Clinical data, use of guideline directed medical therapy and devices, cardiac imaging tests, mortality and CVE were collected and analyzed. Mitral regurgitation was calculated on CMR and was included if it was more than mild. After a mean follow up of 18 months, 53 patients (30%) suffered a CVE (16% heart failure, 14% incident arrythmia, 0,5% stroke 8% death). Patients with MR (n= 48; 28%) had worse LV ejection fraction (-4,8% mean; p=,02), worse RV ejection fraction (-5,5% mean; p=,03), more hospitalizations due to heart failure (OR 1,78; p=,01), had a trend toward increased mortality although it was not statistically significant (p=,01) and a trend towards late gadolinium enhancement (p,13). There was no association with incident arrythmias (p=,5) or stroke (p=,9) In multivariate analyses (log regression, multiple linear regression) MR was maintained as an independent predictor of worse RV ejection fraction (mean -3,9%; p=,03), and hospitalization for heart failure (OR 3,8; p=,043). There was also a trend toward increased mortality (p=,1) in our population. Figure. In patients with DCM, MR is associated with decreased LV and RV ejection fraction, hospitalization due to heart failure and has a tendency to be associated with mortality. Specific treatment for mitral regurgitation, including percutaneous edge-to-edge repair or surgery according to current guidelines, might decrease the severity of MR in these patients and that could lead to an improved prognosis and less morbidity. Further studies should review the impact of an interventional strategy in mitral regurgitation in patients with DCM. Abstract Figure. Mitral regurgitation in DCM: prognosis.

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Use of beta blockers in dilated cardiomyopathy and relationship with cardiovascular events

European Heart Journal ◽

10.1093/ehjci/ehaa946.2100 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

V Vallejo Garcia ◽

D Gonzalez Calle ◽

J.C Castro Garay ◽

M Garcia Monsalvo ◽

J Borrego Rodriguez ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Late Gadolinium Enhancement ◽

Ejection Fraction ◽

Dilated Cardiomyopathy ◽

Cardiovascular Events ◽

Multivariate Analyses ◽

Beta Blockers ◽

Gadolinium Enhancement ◽

Lv Ejection Fraction

Abstract There is an ongoing debate regarding the use of beta blockers (BB) in heart failure with preserved or intermediate ejection fraction. Most studies with BB included patients with moderate to severe left ventricle (LV) dysfunction and some trials challenge the assumption that BB are an effective therapy in these patients. Furthermore, there are some causes of heart failure where the use of BB is not well defined, particularly patients with DCM and mildly reduced LV ejection fraction. Our objective was to analyze the use of beta blockers in patients with dilated cardiomyopathy and to assess its relationship with LV or right ventricle (RV) ejection fraction, late gadolinium enhancement and cardiovascular events (CVE). A retrospective, case control study was designed including 173 patients (mean age 60 years, 73% males, 36% dyslipemia, 30% diabetes, 20% hypertension, 8% currents smoker, 12% previous atrial fibrillation) with diagnosis of DCM and CMR study in our center between 2014–2020 according to the latest European Society of Cardiology (ESC) definition and the latest updated position paper. Clinical data, use of guideline directed medical therapy and devices, cardiac imaging tests, mortality and CVE were collected and analyzed. After a mean follow up of 18 months, 53 patients (30%) suffered a CVE (16% heart failure, 14% incident arrythmia, 0.5% stroke 8% death). The use of beta blockers (n=152; 87%) was associated with a reduced risk for arrythmias (OR=0.019; p=0.0006) in a univariate analysis. It was not associated with RV ejection fraction (p=0.3), hospitalization for heart failure (p=0.03), mortality (p=0.26), or late gadolinium enhancement (p=0.8). For multivariate analyses (log regression, multiple linear regression) we adjusted for age, cardiovascular risk factors, medications, presence of atrial fibrillation, use of devices, LV and RV ejection fraction and presence of late gadolinium enhancement. In our multivariate analyses the use of beta blockers was an independent predictor of improved left ventricle ejection fraction (5.8% mean; p=0.009) and was associated with a marked decrease in the risk of incident arrythmias (OR=0.028; p=0.002) and in mortality (OR=0.068; p=0.041). In patients with DCM, the use of beta blockers is associated with improved LV ejection fraction and a statistically significant reduction in mortality and incident arrythmias. Beta blockers should be recommended irrespective of LV ejection fraction in order to decrease morbidity and mortality in patients with dilated cardiomyopathy. Further studies should assess the contribution of beta blockers in specific etiologies of dilated cardiomyopathy where they could be most helpful and could help to identify the best candidates for early initiation of heart failure therapy. Funding Acknowledgement Type of funding source: None

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Effectiveness of Medical Therapy for Functional Mitral Regurgitation in Heart Failure With Reduced Ejection Fraction

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2020.05.079 ◽

2020 ◽

Vol 76 (7) ◽

pp. 883-884

Author(s):

Anna Sannino ◽

Sivakumar Sudhakaran ◽

Gregory Milligan ◽

Anima Chowdhury ◽

Ayman Haq ◽

...

Keyword(s):

Heart Failure ◽

Mitral Regurgitation ◽

Ejection Fraction ◽

Medical Therapy ◽

Functional Mitral Regurgitation ◽

Reduced Ejection Fraction

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The Results of the Use of Angiotensin Receptor Inhibitors and Neprilisin in Secondary Functional Mitral Regurgitation in Outpatient Practice

Annals of the Russian academy of medical sciences ◽

10.15690/vramn1462 ◽

2020 ◽

Vol 75 (5) ◽

pp. 514-522

Author(s):

Alexey S. Ryazanov ◽

Konstantin I. Kapitonov ◽

Mariya V. Makarovskaya ◽

Alexey A. Kudryavtsev

Keyword(s):

Heart Failure ◽

Left Ventricle ◽

Mitral Regurgitation ◽

Effective Area ◽

Left Ventricular ◽

Functional Mitral Regurgitation ◽

Angiotensin Receptor ◽

Optimal Drug ◽

Patients With Heart Failure ◽

Valsartan Group

Background. Morbidity and mortality in patients with functional mitral regurgitation (FMR) remains high, however, no pharmacological therapy has been proven to be effective.Aimsto study the effect of sacubitrile/valsartan and valsartan on functional mitral regurgitation in chronic heart failure.Methods.This double-blind study randomly assigned sacubitrile/valsartan or valsartan in addition to standard drug therapy for heart failure among 100 patients with heart failure with chronic FMR (secondary to left ventricular (LV) dysfunction). The primary endpoint was a change in the effective area of the regurgitation hole during the 12-month follow-up. Secondary endpoints included changes in the volume of regurgitation, the final systolic volume of the left ventricle, the final diastolic volume of the left ventricle, and the area of incomplete closure of the mitral valves.Results.The decrease in the effective area of the regurgitation hole was significantly more pronounced in the sacubitrile/valsartan group than in the valsartan group (0.070.066against0.030.058sm2; p=0.018)in the treatment efficacy analysis, which included 100patients (100%). The regurgitation volume also significantly decreased in the sacubitrile/valsartan group compared to the valsartan group (mean difference:8.4ml; 95%CI, from 13.2 until 1.9;р=0.21). There were no significant differences between the groups regarding changes in the area ofincomplete closure of the mitral valves and LV volumes, with the exception of the index of the final LV diastolic volume (p=0.07).Conclusion.Among patients with secondary FMR, sacubitril/valsartan reduced MR more than valsartan. Thus, angiotensin receptor inhibitors and neprilysin can be considered for optimal drug treatment of patients with heart failure and FMR.

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Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure

Cardiovascular Revascularization Medicine ◽

10.1016/j.carrev.2019.06.008 ◽

2020 ◽

Vol 21 (1) ◽

pp. 52-60 ◽

Cited By ~ 4

Author(s):

Tomás Benito-González ◽

Rodrigo Estévez-Loureiro ◽

Pedro A. Villablanca ◽

Patrizio Armeni ◽

Ignacio Iglesias-Gárriz ◽

...

Keyword(s):

Heart Failure ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Mitral Valve Repair ◽

Medical Therapy ◽

Functional Mitral Regurgitation ◽

Valve Repair ◽

Percutaneous Mitral Valve Repair

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Abstract 13745: Severity of Functional Mitral Regurgitation During Maximal Exercise Testing in Heart Failure: Additional Value of Combining Echocardiography with Cardiopulmonary Exercise Testing

Circulation ◽

10.1161/circ.130.suppl_2.13745 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Greta Generati ◽

Francesco Bandera ◽

Marta Pellegrino ◽

Valentina Labate ◽

Eleonora Alfonzetti ◽

...

Keyword(s):

Heart Failure ◽

Mitral Regurgitation ◽

Ejection Fraction ◽

Exercise Testing ◽

Cardiopulmonary Exercise Testing ◽

Functional Mitral Regurgitation ◽

Peak Exercise ◽

Cardiopulmonary Exercise ◽

Pulmonary Hemodynamic ◽

Increased Risk

Background: In heart failure (HF) patients the severity of mitral regurgitation (MR) at rest has a well established prognostic value and its increase during exercise further adds to an increased risk. Our goal was to define the relationship between the degree of exercise MR severity with cardiopulmonary and echocardiographic related phenotypes in a cohort of HF patients. Methods: 71 HF reduced ejection fraction patients (mean age 67±11; male 72%; ischemic etiology 61%; NYHA class I, II, III and IV 13%, 36%, 39% and 12%, mean ejection fraction 33±9%) underwent cardiopulmonary exercise test (CPET) on tiltable cycle-ergometer combined with echocardiography at rest and during exercise. The population was divided into two groups according to the degree of functional peak MR: no to mild/moderate MR (no MR, MR1+ and MR2+) vs moderate/severe MR (MR3+ and MR4+). Results: A good correlation (ρ coefficient= 0.49) was found between the degree of dynamic MR and PASP at peak exercise. Despite similar echocardiographic profile at rest patients with significant peak MR (MR≥3+) had worse exercise performance (lower peak VO2, O2 pulse and workload) and impaired ventilatory efficiency (higher VE/VCO2 slope). Conclusions: In HF patients the severity of exercise-induced MR is associated with the most unfavorable performance and pulmonary hemodynamic response. A combined approach with CPET and echocardiographic assessment can help to early unmask and target functional MR and its related unfavorable phenotypes.

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An Echocardiographic Evaluation of Dilated Cardiomyopathy in a Tertiary Care Hospital

Journal of Nepal Medical Association ◽

10.31729/jnma.3992 ◽

2019 ◽

Vol 57 (215) ◽

Author(s):

Raj Kumar Thapa ◽

Kanchan K.C ◽

Rishi Khatri ◽

Devendra Khatri ◽

Rajeeb Kumar Deo ◽

...

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Left Ventricle ◽

Ejection Fraction ◽

Dilated Cardiomyopathy ◽

Tertiary Care ◽

Left Ventricular ◽

Care Hospital ◽

Echocardiographic Evaluation ◽

Significant Difference

Introduction: Cardiomyopathies are diseases of heart muscle that may originate from genetic defects, cardiac myocyte injury or infiltration of myocardial tissues. Dilated cardiomyopathy is the most common phenotype and is often a final common pathway of numerous cardiac insults. Mostly it remains unknown in the absence of echocardiography, histopathology and genetic evaluation. Though common it is underdiagnosed with not much of data available in our setup.Methods: This study was analytical cross-sectional study of hospital data on Echocardiographic findings in 65 patients of DCM visiting cardiology unit for Echocardiographic evaluation from 1st of February to 31st July 2018 for the period of six months in Shree Birendra Hospital, a tertiary care military hospital at Chhauni, Kathmandu. Pediatric age group patients and those who refused to give consent were excluded. Data obtained were entered in Microsoft Excel 2010 and analyzed by IBM SPSS 21.Results: Among 65 patients enrolled 40 (61%) were male and 25 (39%) female with male to female ratio of 1.6:1. Elderly people (61-75 years) with an average age of 65 were commonly involved and they presented mostly with congestive heart failure, 32 (49%). Echocardiographic evaluation showed 36 (55%) with mildly dilated Left Ventricle (5.6-6.0cm). Majority had reduced Left ventricular systolic function with an average Ejection fraction (EF) of 39.6%. No significant difference between male and female with the average EF% (P=0.990) and there was no significant relation between age and average EF% (P=0.091).Conclusions: Dilated Cardiomyopathy is the commonest cardiomyopathy phenotype mostly presenting with congestive heart failure. It is often underdiagnosed in our part of the world, however echocardiography will easily detect the condition. Keywords: dilated cardiomyopathy; echocardiography; ejection fraction; left ventricle.

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Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

Ukrainian journal of cardiovascular surgery ◽

10.30702/ujcvs/20.4112/051035-039/9.73 ◽

2020 ◽

pp. 35-39

Author(s):

R. V. Buriak ◽

K. V. Rudenko ◽

O. A. Krykunov

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Mitral Regurgitation ◽

Cardiac Resynchronization Therapy ◽

Dilated Cardiomyopathy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Functional Mitral Regurgitation ◽

Reverse Remodeling ◽

Resynchronization Therapy

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR. The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT). Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure. Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915). Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished. Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

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Dilated Cardiomyopathy in Children and Adults: What is New?

The Scientific World JOURNAL ◽

10.1100/tsw.2008.105 ◽

2008 ◽

Vol 8 ◽

pp. 762-775 ◽

Cited By ~ 3

Author(s):

Galal E. Nagib Elkilany ◽

Mustafa A. AL-Qbandi ◽

Khaled A. Sayed ◽

Ibrahim Kabbash

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Mitral Valve ◽

Left Ventricle ◽

Ejection Fraction ◽

Dilated Cardiomyopathy ◽

Diastolic Dysfunction ◽

Left Ventricular Ejection ◽

Global Strain ◽

Independent Risk Factors

Dilated cardiomyopathy (DCM) is the most common form of cardiomyopathy and cause of cardiac transplantation in children and young adults; mortality is high among this patient population. However, mortality, clinical course, and illustrative echocardiographic data of DCM in children and adults are not well established. Our objective was to provide a research article of detailed descriptions of the incidence, causes, outcomes, related risk factors, and new echocardiographic criteria of risk of death from DCM. Our results showed that independent risk factors at DCM diagnosis for subsequent death or transplantation in children cohorts were older age, congestive heart failure, lower left ventricular ejection fraction (EF ≤ 25%), low global strain, significant mitral valve incompetence, pulmonary hypertension, diastolic dysfunction, right ventricular involvement, and cause of DCM (p< 0.001 for all). In adults, low ejection fraction (<30–35%), global peak systolic strain <-7.6%, increased EDV, ESV, LBBB, diastolic dysfunction, and left ventricle dyssynchrony were the main independent risk factors for major cardiac events and need for CRT or transplantation (p< 0.001 for all). Our conclusions were that in children and adults, DCM is a diverse disorder with outcomes that depend largely on cause, age, heart failure status at presentation, and echocardiographic parameters of the heart (systolic and diastolic function of left ventricle, pulmonary artery pressure, global strain, and valvular function of the mitral valve). This study will present new findings in the diagnostic area.

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