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Determinants and clinical outcomes of functional mitral regurgitation improvement following cardiac resynchronization therapy

Session Poster session 3

Speaker Ines Silveira

Event : EuroEcho 2017

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Mitral Valve Regurgitation
  • Session type : Poster Session

Authors : I Silveira (Porto,PT), M Trepa (Porto,PT), R B Santos (Porto,PT), B Brochado (Porto,PT), MJ Sousa (Porto,PT), C Roque (Porto,PT), A Pinheiro-Vieira (Porto,PT), V Lagarto (Porto,PT), A Luz (Porto,PT), S Cabral (Porto,PT), A Hipolito-Reis (Porto,PT), S Torres (Porto,PT)

Authors:
I Silveira1 , M Trepa1 , R B Santos1 , B Brochado1 , MJ Sousa1 , C Roque1 , A Pinheiro-Vieira1 , V Lagarto1 , A Luz1 , S Cabral1 , A Hipolito-Reis1 , S Torres1 , 1Hospital Center of Porto, Cardiology - Porto - Portugal ,

Citation:
European Heart Journal Supplements ( 2017 ) 18 ( Supplement 3 ), iii198

Introduction: Mitral regurgitation (MR) in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF) is associated with a poor prognosis.  The aims of this study were to access the determinants of MR improvement after cardiac resynchronization therapy (CRT) and its impact on clinical outcomes (composite of HF hospitalisations and all-cause mortality). 

Methods: Single-center, retrospective study of CRT implantations between January 2002 and March 2016. Echocardiographic evaluation was performed before CRT implantation and at 6-12 months follow-up. Functional MR was graded, according to quantitative and qualitative methods, as: no MR, mild, moderate and severe MR. MR improvement was defined as a reduction of at least one grade in MR class. CRT response was defined as an absolute increase in LVEF =5% and an improvement in NYHA class =1. Predictors of MR improvement were determined by logistic regression analysis. Variables with p<0.1 in univariate analysis were included in multivariate model.  

Results: We analysed 192 patients (mean age 68.1 ± 9.7 years, 60.4% males, 62% non-ischaemic aetiology, 80.5% NYHA class III), with a mean follow-up time of 50.3 ± 34.5 months. At baseline, MR was present in 85.1% (47.6% mild, 30.2% moderate and 7.3% severe). In patients with significant MR (moderate/severe), an improvement in MR after CRT was observed in 73.6%. MR improvement was associated with: atrial fibrillation, right ventricular lead pacing in the interventricular septum, smaller baseline LV end-systolic diameter (LVESd), wider QRS and LV lead in a posterior position. After multivariate analysis only QRS duration was an independent predictor for MR improvement (OR: 1.08; 95% CI 1.00-1.17 p=0.041). Patients with MR improvement had a higher reduction in LV end-diastolic diameter and LVESd (? 4.7 ± 8.6 vs 0.4 ± 3.4 mm p=0.04 and ? 9.5 ± 15.6 vs 1.4 ± 7.0 mm p=0.017, respectively), and a greater improvement in LVEF after CRT (? 8.3 ± 8.5 vs 4.7 ± 4.8 % p=0.032). They also had a higher rate of survival free of composite outcomes at 5 years follow-up (73.8% vs 32.7% p=0.015). The clinical benefit from MR improvement was independent from CRT responsiveness (p-interaction = 0.338). 

Conclusion: Functional mitral regurgitation was prevalent in patients with advanced heart failure undergoing CRT implantation, and there was a significant improvement in valvular regurgitation severity in 3/4 of the patients. This was associated with reverse LV remodelling and improved prognosis, independently from CRT responsiveness.

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